
Class XB53 



Book 



>Ul 



CopyiightlN' . 



mm 



COPYRIGHT DEPOSIT. 






I; 



SCALE OF URINARY COLORS, ACCORDING TO VOGEL. 




Pale Yellow. 

ii. 
Light Yellow. 

in. 
Yellow. 

IV. 

Reddish Yellow. 

v. 



Yellowish Red k 


VI. 


Red 


VII. 


Brownish Red. 


VIII. 


Reddish Brown. 


IX. 


Brownish Black. 



CHICAGO PHOTO-ENG. CO.; CHICAGO 



MANUAL 



OF 



URINARY ANALYSIS 



CONTAINING 



A SYSTEMATIC COURSE IN DIDACTIC AND 

LABORATORY INSTRUCTION 

FOR STUDENTS 



TOGETHER WITH 



REFERENCE TABLES AND CLINICAL DATA 
FOR PRACTITIONERS 



BY 



CLIFFORD MITCHELL, A. B., M. D. 



PROFESSOR OF RENAL DISEASES IN THE CHICAGO 
HOMOEOPATHIC MEDICAL COLLEGE 



THIRD EDITION 

ILLUSTRATED 



PHILADELPHIA 

BOERICKE & TAFEL 
1902 






CONGRESS, 
t*j Cowcg Received 

|C<_AS* ^ XXO No, 

oonr B. 



COPYRIGHTED 
BY 

BOERICKE & TAFEL, 
1902. 



MANUAL 



OF 



URINARY ANALYSIS 



MITCHELL 



PEEFACE. 



THE object of this book is to provide the medical student and 
the practitioner with a practical, accurate, and reliable 
method for examination of the urine. The chemical and micro- 
scopical operations described have been repeatedly verified by the 
author, and nothing of this kind is commended which has not 
stood the test of personal investigation and demonstration. The 
book is original in the sense that unverified quotations from the 
writings of others have been made but to a very limited extent, 
and the clinical matter it contains is, for the most part, based on 
the result of some three thousand examinations, made by the 
author, of the twenty-four hours' urine. 

Complete analyses of the twenty-four hours' urine are given in 
many cases in which death, post-mortem examination, or surgical 
operation during life, confirmed the diagnosis and prognosis pre- 
viously made, based upon the urinary analysis. Results, also, of 
a large number of analyses of the urine in various nervous dis- 
eases are given, together with tables of differential diagnosis in 
Bright's disease, hematuria, pyuria, diabetes, and other maladies 

At the request of a number of physicians in the West, and iu 

accordance with my own desire, I have included in this volume 

the notes on diagnosis by the microscope which I took, not long 

since, in my course with Dr. Charles Heitzmann, of New York 

Cuts of the slides which I obtained from him are also shown. 

CM, 
70 State Street, Chicago, 

June, 1897. 



TABLE OF CONTENTS. 



CHAPTER I. page 
Collection of the Twenty-four hours' Urine 21 

CHAPTER II. 
Significance of the Various Physical Cnaracteristics of Urine. 28 

CHAPTER IH. 
The Reaction, Appearance, Consistency and Odor of Urine, 
and their Significance 37 

CHAPTER IV. 
Clinical Significance of the Color of Urine... 43 

CHAPTER V. 
Exercises in Physical Characteristics 48 

CHAPTER VI. 
Normal Constituents of Urine; Urea 54 

CHAPTER VII. 
Properties and Reactions of Urea 59 

CHAPTER VIII. 
The Determination of Urea 64 

CHAPTER IX. 
Urea: Physiology, Pathology, and Clinical Significance 71 

CHAPTER X. 
Pathology and Clinical Significance of Urea 78 

CHAPTER XI. 
Chemistry of Uric Acid 85 

CHAPTER XII. 
Physiology of Uric Acid 93 

CHAPTER XIII. 
Pathology of Uric Acid 98 

CHAPTER XIV. 
Substances Related to Uric Acid, Xanthine 104 

CHAPTER XV. 
Aromatic Compounds in the Urine, Ethereal Sulphates 109 



TABLE OF CONTENTS. 

CHAPTER XVI. page 

The Aromatic Compounds (concluded) .. 116 

CHAPTER XVII. 
Normal Urinary Coloring Matters and Chromogens 122 

CHAPTER XVIII. 
The Non-nitrogenous Organic Acids of Normal Urine 126 

CHAPTER XIX. 
Carbohydrates Normally Present in Urine 128 

CHAPTEK XX. 

Inorganic Normal Constituents of Urine 131 

CHAPTER XXI. 

Phosphates in Urine, Pathology and Clinical Significance 140 

CHAPTER XXII. 
Chlorides in the Urine 151 

CHAPTER XXIII. 
Inorganic Sulphates in the Urine 157 

CHAPTER XXIV. 
Proteids: Abnormal Constituents of Urine 162 

CHAPTER XXV. 
Clinical Test for Serum-albumin _. 164 

CHAPTER XXVI. 
Life-insurance Tests for Albumin 168 

CHAPTER XXVII. 
Life-insurance Tests (continued) 174 

CHAPTER XXVIII. 
Life-insurance Tests (continued). 178 

CHAPTER XXIX. 
Miscellaneous Tests for Albumin 181 

CHAPTER XXX. 
Quantitative Determination of Albumin in the Urine 184 

CHAPTER XXXI. 
Clinical Significance of Albuminuria 189 

CHAPTER XXXII. 
Proteids (continued) 193 

CHAPTER XXXIII. 
Sugar in the Urine 207 

CHAPTER XXXIV. 
Life insurance Tests for Sugar 212 



TABLE OF CONTENTS. 

CHAPTER XXXV. page 

Delicate Tests for Sugar _. 217 

CHAPTER XXXVI. 
Quantitative Determination of Sugar 220 

CHAPTER XXXVII. 
Clinical Significance of Glycosuria 228 

CHAPTER XXXVIII. 
Acetone and Allied Substances..- 232 

CHAPTER XXXIX. 
Abnormal Coloring* Matters in Urine. Bile 236 

CHAPTER XL. 
Animal Bases in Urine. Toxicity of Urine 245 

CHAPTER XLI. 
Urinary Sediments, Chemical Examination . 253 

CHAPTER XLII. 
Microscopical Examination of Urine, Acid Urine 25? 

CHAPTER XLIII. 
Sediments Found in Alkaline Urine 273 

CHAPTER XLIV. 
Sediments of Infrequent Occurrence. _ 285 

CHAPTER XLV. 
Anatomical Sediments, Blood Corpuscles 289 

CHAPTER XL VI. 
Pus Corpuscles in the Urine 294 

CHAPTER XL VII. 
Epithelium in Urine 299 

CHAPTER XLVIII. 
Tube-casts in the Urine 303 

CHAPTER XLIX. 
Spermatozoa, Connective-tissue, Micro-organisms, Parasites.. 314 

CHAPTER L. 
The Urine and Characteristic Symptoms of Diseases of the 
Kidneys 318 



URINARY ANALYSIS, 



CHAPTER I. 



COLLECTION OF THE TWENTY-FOUR HOURS' URINE. 



Modern examination of urine requires the whole 
quantity for twenty-four hours, which should be col- 
lected day and night separately. By night urine is 
meant only the urine voided after going to bed, and 
including what is voided on rising in the morning. 
All other urine is day urine. Patients should void 
urine before going to stool to avoid loss. It is best to 
begin the collection of the twenty-four hours' urine 
just after breakfast. Clean, wide-mouthed bottles or 
glass pitchers should be used for receiving purposes. 
(Figs. 1 and 2). After the urine is collected, the vol- 
ume of the day and that of the night should be meas- 
ured separately in a graduate (Fig. 3), and the quan- 
tity of each noted down, the two figures added, and 
the urine mixed. 





Fig. 1. Wide- Fig. 2. Neckless Fig. 3. Gradu- 

mouthed quart glass pitcher for ate for measur- 

bottle for re- receiving urine. ing quantity of 

ceiving urine. urine. 

Quantity of urine normal for twenty-four hours:— 

For healthy men, 40 to 50 fluidounces, at most; 30 to 40 for 
women; 10 for children under 3 years of age; 10 to 20 when from 
3 to 6 or 8 years; 20 to 30 between 8 and 12. (Sixteen fluidounces 
make one pint, and 29.52 cubic centimeters, or approximately 30, 
one fluidounce). 



22 URINARY ANALYSIS. 

The normal ratio of day urine to night: — ■ 

The healthy person voids three times as much day 
urine as night. If, however, he drinks freely before 
going to bed the quantity of night urine will be greater ; 
so also if the sleeping hours are long. But, as a rule, 
when the quantity of night urine persistently equals or 
exceeds the day, cardiac or renal disease is present 
The writer has noticed this equality of day urine and 
night in chronic myelitis also. 

The object of collecting 

The twenty-four hours' urine is to compare day with 
night, to compare the total with normal average 
standards, to observe the physical characteristics, and 
to make quantitative estimates of the solids, as urea, 
phosphoric acid, uric acid, together with albumin and 
sugar, if either of the latter is present. In addition 
to the twenty-four hours' urine we must have a sample 
of urine freshly voided, passed, if possible, in presence 
of the physician, for purposes of microscopical exam- 
ination. Women should take cleansing vaginal injec- 
tion or tampon the vagina before passing urine for 
such microscopical examination. The reason of the 
latter precaution is that otherwise vaginal fluids may 
be mixed with urine, and the sediment of the urine be 
largely composed of matters from the vagina. 

In order to preserve the specimen of freshly voided 
urine, add at once ten grains of chloral hydrate, or a 
few drops of a solution of chromic acid, strength one- 
half of one per cent. Then set it aside for at least six 
hours, until the sediment has settled, or settle it in the 
centrifuge. 

Moreover, in cases where albumin in small quanti- 
ties is for any reason suspected, but not found in the 
twenty-four hours' mixed urine, the patient's urine 
should be examined four times, viz. : (1) that passed 
on rising, (2) at noon, (3) at six o'clock p. m., and 
(4) as late as possible at night before going to bed. 
If sugar is suspected, but not found in the twenty- 
four hours' mixed urine, be sure to test the urine 



TWENTY-FOUR HOURS' URINE. 23 

voided at different times in the day, and especially in 
the afternoon. 

The apparatus required for the collection and 
measurement of the twenty-four hours' urine is as 
follows : 

Two clean " wide-mouthed" quart bottles with 
labels and clean corks. 

One small, clean, say eight-ounce, wide-mouthed 
bottle and clean cork. 

If wide-mouthed bottles are not to be had, get 
ordinary clean bottles, and a glass funnel. Let the 
patient urinate either directly into the funnel resting 
in the neck of the bottle, or else use a quart glass 
pitcher (suitable ones may be had at an expense of 25 
to 50 cents) for receiving the voided urine. 

One graduated jar, holding thirty-two fluid ounces, 
graduated also in pints and cubic centimeters. These 
can be had of the dealers in chemical apparatus at a 
cost of $2.25 or thereabouts. 

For comparisons with normal averages see tables in 
Appendix. 

[For microscopical examination of the sediment it is 
always well to have as concentrated a sample of urine 
as possible. Dark-colored urine is likely to have more 
sediment in it than pale, watery urine.] 

REFERENCE TABLE 1.* 
Quantity of Urine per 24 Hours. 

A. Quantity somewhat less than 48 ounces.— 1. Not uncom- 
mon nomally, and especially in women. 2. Normal in children 
under fifteen. 3. May l»e due to (a) vigorous perspiration; (b) hot 
weather; (c) rest; (d) abstention from fluids; (e) copious passages 
from the bowels. 

B. Quantity considerably less than 48 ounces.— 1. In all dis- 
eases except the six or seven mentioned below. 2. In acute dis- 
eases, daily diminution of the urine means increase in the inten- 
sity of the disease. 3. As dropsy increases, urine may diminish. 
4. May be due to ingestion of mineral salts, as those of iron and 
copper; poisoning from external use of pyrogallic acid or aniline 
compounds; from atropine as a collyrium. 5. May be due to 
copious vomiting, or abundant watery stools. 

C. Urine scanty or suppressed.— 1. In all types of violent 



* The Reference Tables are for advanced students and prac- 
titioners. 



24 URINARY ANALYSIS. 

fever and inflammation, as scarlatinal nephritis, yellow fever, 
collapse of cholera. 2. In late stages of chronic nephritis. 3. 
Shock or collapse from internal injuries; reflex shock from 
catheterization; administration of chloroform and ether. 4. 
Poisoning by potassium chlorate, phosphorus, cantharides, 
arsenic, carbolic acid, ergot, iodine, mercury, opium. 5. In cir- 
rhosis ot the liver and in scurvy. 

D. Quantity more than three pints.— 1. Ingestion of 
large quantities of food or drink, especially beer. 2. In cold 
weather. 3. Due to diuretic drugs, as acetate of potassium, 
lithium benzoate and citrate, diuretin, spirit of nitrous ether. 
4. Due to inhalation of oxygen. 5. In diabetes, interstitial 
nephritis, lardaceous disease of the kidneys, pure cardiac hyper- 
trophy, some cases of chronic pyelitis; temporarily, in hysteria, 
and convulsions. 6. In convalescence from severe illness in 
which the urine has been decreased. 7. In typhus at the height 
of the disease, sometimes; in cerebro-spinal fever, sometimes; in 
some cases of rheumatism. 8. In cases of neurasthenia. 



REFERENCE TABLE 2. 

The Quantity of Urine in Bright's Disease. 

A. Diminished: — In acute nephritis, in chronic (diffuse) ne- 
phritis, in chronic congestions, in acute intercurrent attacks of 
chronic nephritis, in last stages of all forms. 

B. Increased: — In chronic interstitial nephritis, in lardaceous 
diseases of the kidneys, after reduction of dropsy in chronic dif- 
fuse nephritis, in convalescence from acute scarlatinal nephritis. 



CLINICAL NOTES. 

1. Polyuria in neurasthenia has been observed by 
the author in a number of cases. Chas. L. Dana says : 
"Neurasthenics of middle age often pass enormous 
amounts of urine of low specific gravity." 

2. I am of the opinion that 50 (1,500 c.c.) ounces 
is above the normal average voided by Americans. 
In 1,300 specimens of the twenty-four hours' urine, 
records of which I have recently gone over, more than 
1,000 were less than 50 ounces (1,500 c.c.) in 
volume. 

3. Diminution in the quantity of urine during or 
after an attack of urinary fever (called, also, urethral 
fever) is a bad sign and means suppression of urine 
and death. 

4. After surgical operations^ in general, on the 
urinary tract, if the volume of urine is good the great- 



TWENTY-FOUR HOURS' URINE. 25 

est danger is averted, but when not a drop is secreted 
for a considerable period the case is usually fatal. 

5. It is said that the time of maximum secretion of 
urine is from 2 to 4 p. m., and the minimum from 2 
to 4 A. M. 

6. Dr. Howard A. Kelly, after numerous ureteral 
catheterizations, calculates that each kidney secretes 
about half a c.c. per minute, a total of 60 c.c. per 
hour. The urine flows into the bladder in gushes at 
intervals of 10 or 15 or 30 seconds. 

CHEMICAL EXERCISE 1. 

1. The student should collect his twenty-four hours' 
urine, according to directions given, day and night 
separately, bring it to the laboratory, and measure it 
in the graduates. He should be required to express 
the results in both French and American measures, 
consulting Table 1 in Appendix. 

For Example: 

Day urine, 900 cubic centimeters, or 30 fluidounces. 

Night urine, 300 cubic centimeters, or 10 fluidounces. 

By use of Table 1, Appendix, the conversion of cubic centime- 
ters into fluidounces is easily acoompl^hed, the fluidounces be- 
ing in the first column of figures to the left, and the cubic centi- 
meters corresponding in the second column. Take the nearest 
figure. For example, if it be required to convert 900 cubic centi- 
meters into fluidounces, run the eye down columns 2 and 5, and 
pick out the nearest figure to 900. It is found in column 2, 
namely, 885. The number of fluidounces corresponding is found 
in the same line in column 1, namely. 29.5, or 30 in round num- 
bers. To convert 300 c.c. pick out 275 in column 5, and find 9.16 
fluidounces corresponding, or in round numbers 10, since 275 is 
considerably less than 300. 

[The division into separate sets of figures for male and for 
female patients is entirely for comparison with normal averages, 
and either set may be used for conversion, since 29.52 c.c. equals 
one fluidounce, regardless of sex.] 

2. Having measured the quantity of day urine and 
of night urine, and expressed each in cubic centimeters 
and in fluidounces, next find the relation of the quan- 
tity of day urine to that of night, by dividing the fig- 
ure representing the quantity of day urine by that of 
the night. In the case above 900 divided by 300 
equals 3. In other words, the day urine in this case 
is three times the night urine. In scientific language 
this is expressed as follows : the ratio of the quantity 



26 URINARY ANALYSIS. 

of day urine to night is as 3 to 1 ; or, briefly, day 
urine : night urine=3 : 1. 

Next consult Table #, Appendix, and ascertain 
whether this ratio of 3 : 1 is normal or not, and if not, 
in how much it differs from normal. In this table a 
ratio of 3 or more to 1 is taken as normal, so in the 
case above the day urine bears a normal ratio to the 
night urine. Suppose, however, the day urine were 
500 c c. and the night urine 1,000 c.c. : — in this 
case 500 divided by 1,000 equals 0.5. The ratio of 
day urine to night is here as 0.5:1. Consulting 
Table 2, Appendix, and finding the nearest figure, find 
0.45 to 1, which is said to be 15 per cent, of normal. 
That is, assuming 3 or more to 1 as the normal ratio, 
which we may indicate by the figure 100 (i. e. 100 
percent, of normal equals normal itself), 0.5 to 1 would 
bear the same relation to 3 : 1 as 15 to 100, hence we 
say 0.5 to 1 is 15 per cent, of the normal. From this 
we establish the following : — 

Rule 1. Divide the quantity of day urine by the 
quantity of night urine. Make a proportion thus: 
Day urine : night equals quotient of day divided by 
night :1. Find in Table #, Appendix, the nearest 
proportion to this, and set down the per cent, figure as 
indicating the relation to normal in your case. 

Next add the figure representing the quantity of 
day urine to that representing the quantity of night 
to get the total volume of urine passed in twenty -four 
hours. In the case above 900 c.c. plus 300 c.c. 
equals 1,200 c.c. or 40 fluid ounces. Now ascertain 
by use of Table 1, Appendix, what relation to the 
average normal quantity this total bears, keeping in 
mind now for the first time the sex of the person. If 
the person is a man, find the nearest figure to 1,200 
in column 2, of Table 1. It is 1,225. Now find on 
the same line in column 3, the figure 90. This means 
that calling normal 100, the total urine in this case 
may be represented by 90, or is, in other words, 90 
per cent, of normal. Do not write 90 per cent, thus, 
.90 per cent. Prefixing a decimal makes it 9-10 of 1 



TWENTY-FOUR HOURS' URINE. 27 

per cent. , a fact seemingly unknown to many students. 
Suppose now the person is a female, who passes 1,200 
c.c. in 24 hours: — Looking in column 5, at the top 
we find the highest figure 1,100 c.c, but going down 
to the ascending scale in column 5, we find 1,200 
there, and to the right in the same line the figure 100, 
or normal. 

The reason of division into two scales, descending 
and ascending, is that normal averages vary according 
to nationality. The French observers, Yvon and 
Berlioz, think 1,100 c.c. the average normal for 
women, while the English make it 1,200. In other 
words, women void 1,100-1,200 o.o. (37 to 40 ounces), 
according to nationality. 

My own statistics show that the French figures are 
nearer right in case of Americans than are the English 
figures. Out of 1,300 different persons where the 24 
hours' urine was measured by the author, nearly 80 
per cent, voided less than 48 fiuidounces of urine. 

4. Finally make out a report on work done as fol- 
lows. 

1. Name of person; 2. Sex; 3. Age; 4. Weight. 

5. Dw urine c.c fl. oz. 

6. Night urine c.c fl. oz. 

7. Ratio of day urine to night 

8. What per cent, this ratio is of the normal ratio per cent 

9. Total volume of urine in 24 hours c.c fl. oz. 

10. What per cent, of the normal average per sex this volume 
is per cent. 

Mix the two samples of urine, day and night, pour- 
ing to and fro, from one graduate to the other, down 
the side of the glass, thus avoiding foam> and set the 
whole aside for the next exercise. 



28 URINARY ANALYSIS. 



CHAPTER II. 



SIGNIFICANCE OF THE VARIOUS PHYSICAL 
CHARACTERISTICS OF URINE. 

The physical characteristics of urine, in addition to 
the twenty-four hours' quantity, include the color, 
odor, specific gravity, from which the total solids may 
be computed when the quantity of urine is known, 
reaction, appearance, consistency, and condition of 
frothiness. 

The color of the healthy filtered urine of twenty-four 
hours is straw yelloio. The color is due chiefly to col- 
oring matters called urochrome and urobilin^ the latter 
a derivative of hematin. See No. 3 on Vogel's Scale, 
Frontispiece. 

The odor of freshly voided urine, contrary to the 
prevailing impression, is decidedly agreeable, and 
called aromatic. The odor of the twenty-four hours' 
urine is usually not unpleasant, though in the case of 
women nearly always slightly pungent from decomposi- 
tion of the mucus present in that part of the urine 
which is oldest. The twenty-four hours' urine of men 
is, in health, often of an aromatic odor, though some- 
times this odor is lost, and a slight indescribable 
pungency noticed. The taste is slightly alkaline or 
bitter. 

The specific gravity of the twenty-four hours' urine 
is not, as formerly stated, 1015 to 1025, but, more 
commonly, 1020 to 1025 in the healthy adult. 

What do we mean by the figures 1015, 1020, etc.? 
Urine is heavier than water, since it contains certain 
salt-like solid matters, derived from the blood, dis- 
solved in it. Every one knows that a pint of water 
in which several ounces of salt are dissolved will 
weigh more than another pint in which no salt is dis- 
solved. Now, urine contains enough salt-like matters 



PHYSICAL CHARACTERISTICS. 




dissolved in it to make one pint of it weigh 1.020 to 
1.025 times more than one pint of water of the same 
temperature. In other words, a pint of urine will 
weigh one and two-hundred ths more than a pint of 
pure water. When this is the case we say the specific 
gravity of the urine is 1020, the decimal point being 
omitted by general consent. 

In order to find the specifio 
gravity of a given sample of 
urine we pour it into a tall 
glass, and let a urinometer float 
in it. Fresh urine should be 
cooled to 77° F. before the spe- 
cific gravity is taken. The 
cooling is best accomplished by 
setting the fluted jar in cold 
water. A urinometer is com- 
posed of a graduated stem, a 
central cylinder-like portion, 
and a bulb at the bottom 
weighted with mercury, the 
whole so constructed that it 
floats upright in water or other 
liquids. In pure water it sinks 
to the very top of its graduation, and this point where 
it sinks in water is marked by the zero sign (0), in some 
instruments, and 1000 in others. It is worth while to 
know whether your instrument is graduated for use in 
liquids of a temperature of 60° or those of 77° F. The 
more modern American urinometers are standardized , 
as it is called, at 77°, sinking to the zero of graduation 
in distilled water of 77° Fahrenheit temperature. The 
urinometers commonly sold, while they may all sink 
to the zero point in pure water, nevertheless will vary 
among themselves considerably in liquids of a high 
specific gravity, 1030 or upwards. 

By the term total solids in urine is meant the 
weight of all the normal solids dissolved in it. Ab- 
normal constituents, as albumin, sugar, bile, blood, 
etc., are not included in this category. 

The most important normal solids are urea, com- 



Fig 4. — TJ rinometer, 
fluted jar, chemical ther- 
mometer; for ascertaining 
specific gravity of urine. 



30 URINARY ANALYSIS. 

mon salt, the sulphates, phosphates, urates, kreatinine, 
and hippuric acid, the average quantity of which per 
twenty-four hours is shown in the following table : 

Table I. 

Constituent. Average amount in 2\ hours. 

Water, 40 to 50 fluid ounces, 1.200 to 1,500 c.c. 

Urea, ..310 to 615 grains, 20.0 to 40.0 grammes. 

Urates,. 6" 12 " 0.4" 0.8 

Hippuric acid, 8" 15 " 0.5" 1.0 

Kreatinine, 8" 20 " 0.5 s ' 1.3 " 

Chlorides,.. ...155 " 245 " 10.0 " 16.0 

Earthy phosphates, 15" 23 " 1.0" 1.5 " 

Alkaline " 30 " 60 " 2.0 " 4.0 

Sulphates,.. ..45" 60 " 3.0" 4.0 

The sura total of these various solids in the urine of 
a healthy adult male, weighing about 150 pounds, on 
ordinary mixed diet, and taking ordinary exercise, 
may be expressed as follows : 

Urea, 500 grains. 

Common salt,. 250 " 

Othersolids, 250 " 

Total solids, 1,000 " 

That is, urea represents about half the total solids 
and common salt about one-quarter. 

In my opinion these figures are maximum ones, and 
much lower results may be obtained by analysis in the 
case of perfectly healthy persons under certain circum- 
stances of age, diet and exercise, as will be shown 
further on. 

The weight of tho total solids in urine, which 
chemists obtain by evaporating the liquid to dryness 
and weighing the solid residue, may, for clinical pur- 
poses, be computed mathematically as follows : 

1. Take the specific gravity of the twenty-four 
hours' mixed urine; 

2. Multiply the last two figures of the specific 
gravity by 2.33 (Haeser's coefficient); 

3. Divide the product by 1,000; 

4. Multiply quotient by number of c. c. of urine voided 
in 24 hours. Result is grammes of solid matter in the 
24 hours' urine. 



PHYSICAL CHARACTERISTICS. 31 

Now, in taking the specific gravity of the urine two 
precautions must be observed : First the urinometer* 
must be fairly accurate: second, the specific gravity 
must be taken at the temperature at which the urin- 
ometer is standardized. 

Pour a sample of the twenty-four hours' urine into 
the fluted jar ; set the latter in a glass of warm or 
cold water; take the temperature of the urine with 
the thermometer; when it is 77° F. , remove the fluted 
jar from the water and take the specific gravity at once. 

I have not been able to draw any deductions what- 
ever from our former method of comparing the total 
solids estimated, as above, with some arbitrary normal 
average, as 58 grammes. When nothing is known 
about the patient, as is sometimes the case, we may 
indeed guess at the amount of " renal insufficiency " 
bv comparing the solids computed as above with 58 
grammes (900 grains). But when the age, weight, 
diet, and exercise of the patient are known, our ideas 
of the relation of solids excreted by him compared to 
the work his kidneys ought to do, are much better. 

For example, take the following : twenty-four hours' 
urine, 900 cubic centimeters (30 fluid-ounces); specific 
gravity 1015. Total solids, 15 times 2 J times 900, 
divided by 1000, equals 31£ grammes, or 488 grains. 
Suppose the patient's condition be unknown. We 
would say, in a general way, that his kidneys were 
doing only half the work they ought to, since 488 is 
about half of 900 to 1000 grains, which we assume 
the normal excretion to be. But suppose the patient 
was above 70 years of age, or, if between 20 and 40, 

* There are two kinds of urinometers, fairly accurate ones, and 
decidedly inaccurate ones. Those made by Squibb are recom- 
mended as being accurate. I know from experience that if thirty 
or forty urinometers are successively floated in the same urine at 
the same temperature, the readings will vary very considerably. 
I have known these variations in urines of high specific gravity, 
1030 or upwards, to be as great as 8 or 10°. Urinometers are 
standardized from chemical solutions, but solutions of the same 
strength of different chemicals give different readings with the 
same urinometer. For example, 2 per c-nt. solutions of urea, 
sodium carbonate, and potassium sulphate gave the writer specific 
gravities of 1009, 1012, and 1017 respectively. Potassium sulphate 
has no water of crystallization in its formula. 



URINARY ANALYSIS. 



weighed only 100 pounds, and was in bed on restricted 
diet? It is evident that in either of these cases we 
might be seriously at fault in assuming renal insuffi- 
ciency. In order to make deductions of any definite 
value from the actual quantity of solids found, says 
Dr. Purdy, careful regard must be paid to certain con- 
ditions and features connected with each individual 
case, the most prominent of which are the weight, 
age, diet, and amount of exercise taken. Purdy's 
rules for making reduction or addition for weight, age, 
diet and exercise involve considerable figuring; so I 
have constructed a table, based on his rules, giving 
reductions or additions for weight and age at a glance. 
The normal average excretion of solids for a person 
between 20 and 40 years of age, weighing 145 pounds, 
on ordinary mixed diet and taking ordinary exercise, 
is assumed to be 945 grains (61.14 grammes). On 
this assumption the following table is constructed : 
Table II. 







Formal Excretion. 




Weight. 








Age 20 to 40. 


Age 40 to 50. 


Age 50 to 60. 


Age 60 to 70. 


Age above 70. 


145 pounds. 


61 ems., 945 grs. 


55 cms., 850 grs. 


48 gm.s., 756 grs. 


42grns.,6*0grs. 


30 guts., 473 grs. 


140 " « 


912 " 


820 " 


730 " 


634 " 


456 " 


135 " „ 


878 " 


790 " 


702 " 


608 " 


439 " 


130 " . 


845 " 


760 « 


675 " 


582 " 


423 " 


125 " . 


812 " 


730 " 


649 «• 


556 " 


•406 " 


120 " . 


780 " 


702 " 


624 " 


530 " 


390 " 


115 - . 


748 " 


673 " 


598 " 


504 " 


374 " 


110 u „ 


715 " 


644 " 


572 " 


478 " 


357 " 


105 " .. 


682 " 


614 " 


545 " 


452 " 


341 ■ 


100 «• . 


650 " 


585 " 


620 " 


426 " 


325 « 


95 u - 


616 M 


556 " 


494 " 


400 " 


309 " 


90 " .. 


585 » 


526 " 


468 " 


374 «» 


293 " 


85 " .. 


552 " 


497 " 


442 M 


348 *« 


276 " 


80 " ,. 


520 " 


468 " 


416 " 


322 " 


260 " 


75 " ^ 


488 «' 


439 u 


390 M 


296 " 


244 " 


70 • ; 


456 u 


410 u 


365 u 


270 " 


228 " 






For weights above.145 pounds (66. kilograms). 




150 • - 


978 " 


880 " 


782 " 


685 « 


489 " 


155 « .. 


1010 •• 


910 " 


S08 " 


707 " 


605 " 


100 " .. 


1042 " 


938 " 


833 ° 


729 " 


621 " 


165 " - 


1074 " 


967 " 


859 " 


751 " 


536 " 


170 " .. 


1106 " 


998 " 


885 " 


773 " 


553 " 


1*5 " . 


1138 " 


1024 " 


910 - 


795 " 


569 " 


180 " „ 


1170 " 


1053 " 


936 " 


817 - 


585 " 


185 " - 


1202 " 


1082 " 


962 " 


840 " 


601 " 


190 " « 


1234 " 


1110 " 


988 " - 


862 " 


617 " 


195 " . 


1266 " 


1140 " 


1014 - 


884 " 


633 : 


200 «• .. 


1298 " 


1168 " 


1040 " 


907 " 


649 " 


205 '• - 


1330 " 


1197 " 


1066 " 


930 ■ 


665 " 


210 " .. 


1362 " 


1226 " 


1092 " 


952 " 


681 " 


215 " . 


1394 " 


1255 " 


1118 " 


973 " 


697 - 


220 *' .. 


1426 " 


1284 " 


11*4 " 


995 ' 


713 " 


225 " . 


1458 " 


1312 " 




1020 " 


729 " 



PHYSICAL CHARACTERISTICS. 38 

The preceding table, page 32, gives the normal 
averages of total solids in the urine of persons on 
ordinary diet, taking ordinary exercise. It represents 
the mean of the combined observations of eight 
writers. 

The table gives corrections for age and weight only. 
From these figures deduct 33 per cent, for fasting two 
or more days, as in some fevers, or 12 to 16 per cent, 
for a sparing diet, or 10 per cent, when the person is 
not eating as freely as when in health. 

Furthermore, deduct 10 per cent, if the person is in 
bed, or 5 per cent, if confined merely to the house. 

Examples illustrating the above : 

1. Solids computed, 530 grains in the twenty- four 
hours' urine. 

Patient 35 years old; weight, 155 pounds; diet, 
ordinary; exercise, ordinary. 

Deduction. — A person 35 years old, weighing 155 
pounds, should excrete (Table II.), on ordinary diet and 
exercise, 1010 grains. The person in question excretes 
530 grains. Therefore he or she is passing only about 
half what should be excreted in twenty-four hours. 

2. Solids computed, 530 grains in twenty-four 
hours' urine. Patient 65 years old, weighs 140 
pounds, eats sparingly, and is confined to the house. 

Deduction. — A person 65 years old, weighing 140 
pounds, should pass (Table II.) 634 grains of solids 
when on ordinary diet and exercise. But as the diet 
is sparing, deduct from 12 to 16 per cent, of 634, say 
90 grains; 634 — 90 equals 544 grains. Still further, 
deduct 5 per cent, from the figure last obtained since 
the patient is confined to the house. Five per cent, of 
544 is about 28 grains. Final figure, 544 — 28, or 
about 515 grains. In other words, a person under 
these circumstances should void about 515 grains of 
solids in twenty-four hours. The amount computed is 
530 grains. Therefore, he or she is passing just about 
what would be expected under the conditions. 

It goes without saying that a faulty urinometer will 
cause considerable difference in results. 
3 



34 URINARY ANALYSIS. 

Example 3. — Urine in twenty-four hours, 1000 c.c. 
(33 fl. ozs.); specific gravity b}^ one urinoineter, 
1030; by another, 1022. 

Patient weighs 175 pounds; age, 30; diet, hearty; 
exercise, vigorous. By one urinometer, the first, he 
is voiding 70 grammes (30 times 2-J- times 1000, 
divided by 1000), or 1085 grains. By the second 
instrument he is voiding 51 grammes, or 890 grains. 
A person of his a^e, weight, etc., should void at least 
1138 grains (Table IT.). If the first urinometer is 
correct, he is voiding only about 50 grains short of 
what we should expect. If the second urinometer is 
correct, he is voiding 250 grains less than he ought; 
890 grains would represent the excretion of a person 
weighing 40 pounds less than the person in question. 

The whole calculation, with the table and reduc- 
tions, depends greatly on the accuracy of the urin- 
ometer used. 

Lastly, if the urine contains any sugar or albumin 
in abundance the method of computing solids is not 
trustworthy, since the specific gravity of the urine is 
changed by the abnormal constituent present. Also 
in cases where there is considerable polyuria an inac- 
curate urinometer will give rise to a considerable error 
in results. For example, suppose the total quantity 
of urine in twenty-four hours be 2,800 c.c, or 93 fluid- 
ounces. Suppose the true specific gravity at 77° F. 
be 1006. In this case the total solids are 6 times 
2.33 times 2,800, divided by 1,000, equals 39 gram- 
mes, or 600 grains. But a urinometer giving a read- 
ing of 1008 would indicate total solids amounting to 
52 grammes, or 800 grains, the error amounting to 
200 grains. 

When there is no great polyuria the total solids may 
be computed from saccharine urine by first ferment- 
ing with yeast, then filtering, and taking specific 
gravity at 77° F. 

PRACTICAL APPLICATIONS TO DIAGNOSIS AND TREATMENT. 

1 . In gynecological cases and nervous diseases Dr. 
"N. B. Delamater has shown for fifteen years past that 



PHYSICAL CHARACTERISTICS. 35 

deficiency in solids, with accompanying symptoms, 
often yields to eliminative treatment. 

2. Dr. J. H. Etheridge has, independently, con- 
firmed the statements so often made by Dr. Delamater, 
showing that amenorrhoeas, neuralgias, pelvic perito- 
nitis,- dyspepsias, bronchitis, cutaneous eruptions, 
headaches, backaches, leucorrhoeas, nervousness, and 
insomnias accompany deficient excretion of urinary 
solids. Women passing not to exceed 400 grains of 
solids daily present various degrees of nervous irrita- 
bility. When less than 300 grains are passed the con- 
dition of nervousness becomes serious; bronchitis, 
neuralgia, perimetritis or pleurisy may then result 
from taking cold. A very close relation exists 
between renal insufficiency and pelvic disorders. 
Many disorders of this character are relieved by 
including in the treatment remedies that increase the 
urinary solids. 

3. Deficiency in solids in the urine of men I have 
found to indicate unrecognized interstitial nephritis in 
some cases; in others, serious nervous disorders. 
Purely says the same thing so far as the renal condi- 
tion is concerned. In such cases collect the twenty- 
four hours' urine, day and night separately, deter- 
mine urea and phosphoric acid, look for casts, and 
examine the patient's chest for cardiac lesions. 

4. The differential diagnosis between diabetes in- 
sipidus and simple hydruria may be made by deter- 
mining the total solids, which in the former disease 
are largely in excess of the normal average. 

5. In fevers and acute diseases, as pneumonia and 
typhoid fever, the severity of the disease is indicated 
by increased quantity of solids in the urine ; if, on the 
other hand, the temperature is high, but the excretion 
of solids in the urine is deficient, eliminative treat- 
ment should be employed, since elimination is evi- 
dently defective. 

6. In diseases in which there is exudation, marked 
increase in the quantity of solids in the urine is a good 
sign, and indicates that eliminative treatment is not 
needed. 



36 URINARY ANALYSIS. 

7. By subtracting the total urea determined in the 
twenty -four hours' urine from the total solids computed, 
an idea may be had as to the general composition of the 
urine in question. In cases in which the total urea is 
greater than three times the total salts (difference be- 
tween total solids and total urea) I have observed 
great mortality. 



REACTION OF THE URINE. 



37 



OHAPTEE III. 

THE REACTION, APPEARANCE, CONSISTENCY AND ODOR 
OF URINE, AND THEIR SIGNIFICANCE. 



The next physical characteristic to be con- 
sidered is the reaction of the urine, whether 
acid, neutral or alkaline. 

The reaction of the normal twenty-four 
hours' mixed urine is slightly acid, made so 
by the presence of sodium acid phosphate. 
Blue litmus paper is turned slightly reddish 
when held immersed in it some little time. 

If the urine when boiled turns cloudy, and 
the cloudiness is dispelled by adding a few 
drops of 20 per cent, acetic acid, and shaking, 
the reaction is not sufficiently acid. Normal 
urine should be as clear after it is boiled as 
before, when not over twenty- four hours' old. 

Litmus paper is sensitive to light and air, 
and should be kept in small salt-mouthed bot- 
tles, tightly corked, and covered with paper to 
keep out the light. I prefer soft litmus paper 
to stiff, for the reason that the latter in small 
pieces has a way of curling up and floating on 
the surface of urine, instead of sinking quickly, 
when dipped into it, hence it is less economical 
for use. In larger pieces the stiff paper is easily 
managed. Different articles of litmus paper 
vary in the tint of red obtained by dipping into 
the same sample of urine. This is because 
some paper is impregnated with more coloring- 
matter than others. Some blue litmus paper 
will give a fairly bright red tint with urine 
which when boiled becomes cloudy, the cloud- 
iness being dissipated by addition of acid, so 
that deficiency in acidity should be tested for 



Fig. 5. 

Litmus 

Pencil. 



38 URINARY ANALYSIS. 

by this means as well as by use of litmus. Litmus 
pencils {Fig. 5) may be used instead of litmus paper and 
are preferable in that they do not lose their color as 
does litmus paper. One end of the pencil is blue the 
other red. Kub the sharpened ends on paper and get 
ready -made litmus paper of either color. 

The appearance of normal urine when freshly 
voided is invariably clear. The twenty-four hours' 
urine is almost always slightly hazy, when looked at 
in a glass held below the window sill. Urine voided 
in a cold room, 40° to 35° F. , may soon, though 
normal, become turbid. The urine of even healthy 
women almost always, on standing, deposits a more 
or less abundant whitish sediment, derived chiefly 
from vaginal fluids mixed with it. 

The consistency of normal urine is that of water — 
easily dropping. Normal urine foams when shaken, 
but the foam disappears in time, not remaining per- 
manently on top of the liquid. 

Now, the chief clinical points of value to be derived 
from study of the physical characteristics are these : 

Decrease in the twenty-four hours' urine is usually 
accompanied by increase in the color, odor, acidity, 
and specific gravity. If a patient passes a pint in 
twenty-four hours, the color will be darker, the odor 
more noticeable, the acidity greater, and the specific 
gravity highe \ than when he passes three pints. Ex- 
ceptions may be found in nephritis, and especially in 
atrophy of the kidney, when the specific gravity is low. 

As a rule the urine voided at 10 :30 a. m. should not 
be strongly acid. Keyes thinks this an important 
point in the diagnosis of the cause of pain in the back, 
w T hich he thinks renal in origin, no other cause being 
apparent, provided the urine voided at 10:30 a. m. is 
noticeably acid. Physiologically the urine at this 
hour should be less acid than at other times, that is it 
should be neutral or only slightly alkaline. 

In general, the urine of digestion (two hours, say, 
after a meal) is less acid, unless acid foods or drinks be 
taken. This urine is called urina cibi, the urine of 
food. 



REACTION OF THE URINE. 89 

Urine voided on rising in the morning is called 
urina sanguinis, urine of the blood, because it is voided 
when the stomach is empty. It is deeper in color, 
higher in gravity, etc. , than at other times of the day ; 
in other words, its characteristics are increased in 
intensity. 

Urine voided after copious draughts of fluids is 
called urina potus, the urine of drinking. Its charac- 
teristics are diminished, *. 0., it has less color, less 
acidity, etc. Its specific gravity may be very low, 1005 
even. 

We find, as a general rule, that polyuria, or voiding 
of increased urine in twenty-four hours, is attended by 
diminution in the intensity of the physical characteris- 
tics, except in diabetes mellitus, in which one charac- 
teristic, specific gravity, is greatly increased. 

Unusual shade of color, as greenish, deep yellow, 
or deep red, may be seen when bile is in the urine, or 
when certain drugs containing coloring-matters have 
been taken, as santonin, rhubarb, etc. 

In cardiac or renal diseases when a patient who has 
been in the habit of passing light-colored urine sud- 
denly and without any apparent cause, begins to void 
urine of a bright red tint, death is apparently inevit- 
able. I have noticed this change but twelve times, 
and all the patients concerned died in a few weeks or 
months, only one surviving as long as a year after the 
color changed. The particular color I have been able, 
after much trouble, to imitate by diluting a solution of 
the oxychloride of iron (not per-chloride). The 
appearance of the urine in these twelve fatal cases 
was like that of a diluted solution of oxychloride of 
iron, in that it was clear, or nearly so, when looked at 
through the sides of the glass, but inky when looked 
at from above, in this respect differing from bichro- 
mate solutions, with which I first tried to imitate the 
color. !Such uiine is usually more or less turbid from 
mucus or urates, seldom contains much albumin and, 
usually, but a few casts, yet it is one of the worst 
prognostic signs I have yet observed. 



40 URINARY ANALYSIS. 

The chief points in regard to the odor of urine are as 

follows : 

Urine which smells like ammonia when freshly 
voided is found in inflammations of the bladder, espe- 
cially in the cases of old men with enlarged prostates, 
and with pus in their urine. Such urine is irritating 
to mucous surfaces. Normal urine, when old enough, 
i. e., "stale," takes on this ammonia- like odor, but 
should not do so when only twenty-four hours old. 

Urine which soon acquires & putrid o&oy , something 
like that of decayed meat, has decomposing mucus, 
pus, or blood in it. The urine of healthy women may 
become putrid from decomposing mucus soon after the 
twenty-four hours have passed, especially in warm 
weather. 

Urine which is turbid, when freshly voided, is found 
chiefly in inflammations of the bladder and contains 
pus, usually with micro-organisms, and suspended 
phosphates, Sometimes, however, the turbidity of 
freshly voided urine is due wholly to suspended simple 
phosphates : if it clears up on addition of a few drops 
of acid, and shaking, this latter is the case, and usu- 
ally nothing serious is indicated. But urine turbid 
when freshly voided, which does not clear on addition 
of acid, and especially if it have an ammonia-like odor, 
is indicative of disease, usually of the bladder. It is 
airline, turning the red paper blue, and called alka- 
line from volatile alkali, i. e., ammonia. 

Urine which, turns the red paper blue, but has not 
rne ammonia-like odor, and which, if turbid, clears on 
addition of acid, is said to be alkaline from fixed alka- 
li, i. e., the carbonates of sodium and potassium. 
Such urine, if clear when freshly voided, becomes tur- 
bid when boiled, but clear again when acid is further 
added. This does not signify presence of albumin, as 
supposed by some, but is due to a precipitate of simple 
phosphates, caused probably by increase in the alka- 
linity produced by the boiling, which drives off car- 
bonic acid. 

Urine which, on standing, soon deposits a pinkish 
sediment {urates) adhering closely to the sides of a 



REACTION OF THE URINE. 41 

chamber- vessel or streaking the sides of a glass vessel, 
is too acid in reaction (hyper -acid). Such urine we 
see in what is rather vaguely called Uthcemia or uric- 
cemia, a condition in which uric acid formed in the 
body is not sufficiently excreted or else not excreted 
with regularity. In such urines we often see little 
reddish or brownish specks, which are very heavy, 
and settle quickly to the bottom. These are uric acid 
crystals. 

Urine which, on standing for a time, becomes 
cloudy, and then when heated becomes clear again, 
contains a sediment which is composed of urates (com- 
pounds of uric acid) especially noticeable in cold 
weather. 

As to the character of the foam in urine, it may be 
said that even slightly albuminous urines foam abund- 
antly, and the foam is persistent. Albuminous urines 
give rise to much foam in the urea instruments, as we 
shall learn further on. Urine containing sugar foams 
readily, and the foam is persistent. I have seen some 
cases of persistent foam in which I could find nothing 
unusual in the urine, except a sediment of uric acid 
and urates. 

When the urine is of some unusual color and the 
foam has a faint or marked color, held in the right light, 
bile is present, and a slight or marked odor of ox-gall 
may be noticed. This is, on the whole, the easiest and 
simplest test for bile that we have. 

Urine having a sediment which sticks to the glass 
contains pus, more or less mixed with mucus, and 
altered by the ammoniacal alkali present in such con- 
ditions. This is the easiest and quickest way of recog- 
nizing pus, since mucus alone does not stick to the 
glass. But all urine containing pus does not have this 
sticky sediment. In acid urine pus shows large flocks 
which rapidly settle, but do not stick to the glass. Set 
the bottle aside in a warm place, and in a day or two 
the sediment, if pus, will stick to the glass. 

Patients sometimes pass urine containing gases, 
which are, probably, carbonic acid gas and nitrogen. 
The gases escape in large bubbles, and the unusual 



42 URINARY ANALYSIS. 

occurrence generally causes much alarm. These gases 
form especially in eases when urine containing sugar 
is for any reason retained in the bladder where bac- 
terial fermentation sets in, thus forming the various 
gases. The condition is known as jmeumaturia. 
Keyes says that pneumaturia may exist without sugar 
being in the urine. The gases are usually odorless, 
but I have heard of one case in which an odor like 
sulphuretted hydrogen was claimed. Pneumaturia 
may exist without vesicointestinal fistula. Keyes has 
seen it only in patients who used the catheter. 

In certain cases it may be worth while to take the 
temperature of the freshly voided urine. For this pur- 
pose a clinical thermometer is useful. 



REFERENCE TABLES. 43 



CHAPTER IT. 

CLINICAL SIGNIFICANCE OF THE COLOR OF URINE. 
REFERENCE TABLES FOR THE PRACTITIONER. 

The following pages give in tabular form the clin- 
ical significance of the various physical characteristics 
of the urine, as set forth in the preceding chapters. 

REFERENCE TABLE 3. 
Synopsis for Color. 

I. Pale urines. — Either (A) physiological, after drinking, or (B) 
pathological; the latter in (a) polyuria, as in neurasthenia, hys- 
teria; (b) in diabetes insipidus; (c) in interstitial nephritis; (d) in 
lardaceous disease of the kidneys; (e) in convalescence from many 
acutn diseases; (/) poisoning by duboisin; (g) anaemia; (h) diabetes 
insipidus. 

II. Urines lighter than straw-yellow but not pale.— (a) That 
of neurotic persons; (&) of most women; (c) normally in children; 
(d) sometimes in diseases of the prostate; (e) in cases of sexual de- 
bility: light, phosphatic sediment in the urine; (/) diabetes insipi- 
dus (milder cases). 

III. Lemon-yellow. — Diabetes mellitus, when much sugar is 
present. Said to occur in cholera and in spinal disease. 

IT. Peculiar bright-yellow tints. — Due to taking internally 
of gamboge, senna, logwood, picrotoxin. santonin, rhubarb. 

V. Darker than straw-yellow.— Approaching red.— Diminu- 
tion in volume of urine; physiologically, after perspiration, or 
when but little liquid is taken in the diet. 

YI. Reddish urine. — In fevers and inflammations. Sometimes 
due to sediment of urates colored red by urcerythrine, a patho- 
logical coloring matter; in such case filter the urine, and the 
tin*" '• "iv be yellowish rather than reddish. 

VII. Peculiar bright-red tints.— Due (a) to presence of bile, 
blood, or (b) to coloring matters from such substances taken 
internally as logwood, madder, bilberries, fuchsin, aloes, alizarin. 

VIII. Orange-red.— Ingestion of santonin, chrysophanic acid. 

IX. Dark-red.— (a) In severe acute febrile diseases; (6) blood in 
the uriue; (c> external use of aniline chlorhydrate. 

X. Brownish tints.— Brown-red, in acute febrile disorders or 
inflammations; brown-yellow or red-brown, due to ingestion of sen- 
na,rhubarb,chelidonium; greenish-brown, due to bile in urine; dark 
brown, (a) due to bile or blood in urine; (b) found in long continued 
intermittent fever; (c) due to external use of pyrogallic acid; 
brown to brown-black, in so-called methaemoglobinuria; in melan- 
otic sarcoma; in wasting diseases; in this case the color is due to 
the presence in the urine of a black pigment called melanin; the 
urine, if not dark when voided, darkens on standing; this is not 



44 URINARY ANALYSIS. 

the same coloring matter found in the urine in carbolic -acid 
po'sonin?. In carbolic-acid poisoning. 

XI. Black urine. — Brownish-black, see preceding; (a) in 
poisoning by sulphuric acid, creosote, arseniuretted hydrogen, 
potassium chlorate; (b) ingestion of naphthalin. hydrochinon, 
resorcin, pyrocatechin; (c) inunction of tar; (d) melanuria (on 
standing). Urine containing melanin darkens on standing, and 
becomes intensely black when oxidized by ferric chloride or other 
oxidizine agents. 

XII. Green tints.— (a) Greenish-yellow, greenish-brown, see 
above; (b) dirty-green or blue in cholera and typhus, when urine 
putrefies; (c) dark-green in carbolic-acid poisoning. Greenish to 
gr*s<-green is said to have been seen in cystitis and in Bright's, 
in alkaline decomposed urine. 

XIII Blue* tints.— (a) See above: (b) In typhoid fever, 
chronic affections of the spinal cord; (c) Presence of indigo. (See 
Sediments.) 

Pale urines are deficient in urohematin, the nor- 
mal coloring matter of urine. Lemon -yellow urine 
contains uroxanthin. The pinkish or rosy tints of 
urates in the sediment are due to uraerythrin. The 
blue pigments are cyanurin (uroglancin) and indigo. 
The greenish may be due to mixtures of uroxanthin 
with the blue pigments. (Thudichum.) 



REFERENCE TABLE 4. 

Odor. 

Odor slightly aromatic— Health. 

Prouninced aromatic odor, not offensive.— Decrease in quan- 
tity of urine, as after perspiration, in fevers, etc. 

Slightly pungent odor.— Normal after twenty-four hours in 
m^n. 

Pungent odor.— Common after twenty-four hours in urine of 
women containing much mucus. 

Putrid odor.— Due to decomposing mucus, pus, blood. 

Odor of ammonia.— Alkaline urine either stale or, if fresh, 
due to diseases of the prostate, bladder, or kidneys; usually cys- 
titis. 

Odor of sulphuretted hydrogen.— Decomposing mucus; com- 
mon in the stale urine of diseases of the bladder and prostate, 
and in that of women containing leucorrhoeal fluid. Also in urine 
containing cystin. 

Sweetish odor.- Sugar in the urine. 

Sour milk or yeasty odor.— Stale urine containing sugar. 

Odor of tainted meat. — Stale urine containing albumin, pus, 
or blood. 



* Dr. Wesley A. Dunn tells me that that the urine mav be col- 
ored blue as a result of application of methyl blue locally to the 
throat, as also wheu taken mtt-niall. . 



REFERENCE TABLES. 



45 



Odor of cliloroforni-acetic acid.— Acetone in the urine, as in 
diabetes with acetonuria. 

Odor of violets. — Ingestion of oil of turpentine 

Odor of sweet-briar.— Fresh urine containing cystin. 

Odor of ox-grall. — Bile in the urine. 

Substances which more or less communicate their own odors 
to urine are: 



Asafoetida, 
Asparagus, 
Beef extract, 
Cauliflower, 



Cantor Oil, 

Coffee, 

Copaiba, 



Cubebs, 
Garlic, 
Oil of tolu, 



Onions, 
Sandal wood, 
Valerian. 



REFERENCE TABLE 5. 

Specific Gravity. 

1020 to 1025.— Usual normal range. 

1013 to 1060. —Possible range when sugar is in the urine. 

1002 to 1035. — Possible range when albumin is in the urine. 

Above 1040. — Almost invariably diabetes mellitus; invariably, if 
polyuria. 

1025 to 1030. — May be normal in those leading sedentary lives. 

1025 to 1040. — Possibility of diabetes mellitus. acute nephritis, 
cong stion of kidneys, oxaluria. some eis^s of neu- 
rasthenia, uric acid sediments, acute diseases gen- 
erally. Functional albuminuria. 

1020 to 1015. — May be normal in those who drnk copiou-ly. Pos- 
sibility of neurasthenia, anaemia in women, chronic 
nephritis. 

Below 1015. — Diabetes insipidus; neurasthenia: chronic nephritis; 
lardaceous disease of kidneys; hysteria; anaemia. 



REFERENCE TABLE 6. 
Chemical Reaction. 

Slightly acid. — Usual normal reaction of the twenty-four 
hours' urine. 

Plainly acid. — Urine diminished in twenty-four hours' quan- 
tity: in those who drink but little water; due to muscular exer- 
tion, meat diet, ingestion of sacchar n: stale urine which has 
undergone acid fermentation. Milk diet sometimes increases 
acidity of urine 

Strongly acid. — Due to ingestion of acids, as boracic. benzoic 
or acid salts, as perchloride of iron. Horsford's acid phosphates, in 
febrile disorders; in the uric acid diathesis; in certain diseases of 
the liver. 

Neutral.— Copious drinking; usual after meals. 

Alkaline. — Three or four hours a*"ter meals; after perspiring co- 
piously; after hot baths; due to \ egetable diet; after copious vomit- 
ing; from ingestion of alkaline carbonates or salts of vegetable 
acids, as in mineral waters containing the above; lithia waters and 
tablets, lithium beazoate, citrate, etc., from fixed alkali in debil- 
ity, nervous exhaustion, anaemia and chlorosis, pulmonary dis- 
orders, some acute diseases (pneumonia, typhus, enteritis, flatu- 



46 URINARY ANALYSIS. 

lent dyspepsia; from volatile alkali in stale urine, or, when in 
freshly voided urine, cystitis or pyelitis). 

CLINICAL NOTES ON REACTION. 

1. Urine of highly acid reaction is irritating to the 
mucous membrane of the urinary tract and aggravates 
an}^ existing disease, especially in women. 

2. Alkaline urine (fixed alkali) is somewhat ir- 
ritating. 

3. Ammoniacal urine causes the greatest distress of 
all. The agony of a patient with prostatic abscess, 
who voids strongly ammoniacal urine, is extreme. 



REFERENCE TABLE 7. 

The Quantity, Specific Gravity, and Color of Urine in 
Pathological Conditions. 

A. Quantity small, specific gravity low, color pale.— Suspect 
chronic nephritis; uraemia. 

B. Quantity large, specific gravity high, color paler than 

normal.— Suspect diabetes mellitus. 

C. Quantity large, specific gravity not above normal, color 
pale. — Suspect diabetes insipidus, neurasthenia, interstitial 
nephritis, lardaceous disease of kidneys, reduction of dropsy, con- 
valescence from acute diseases. 

D. Quantity small, specific gravity high, color high.— (a) 
acute febrile diseases; (b) dropsy; (c) to a less degree, in cerebral 
and gastric neurasthenias, and in oxaluria: (d) in acute and 
chronic renal hyperemia; (e) in certain hepatic disorders. 

CLINICAL NOTE. 

Urine as described in D has been observed by the 
author in (a) cases of gall-stone colic ; (b) just preceding 
uraemic convulsions ; (c) commonly in oxaluria (500-6OU 
c.c. of urine in 24 hours); (d) in obscure mental 
diseases (insanity?) soon terminating fatally, with 
marked relative excess of uric acid in solution. 



REFERENCE TABLE 8. 
Consistency and Frothiness. 

A. Increased consistency. — Presence of mucus and pus, 
especially in alkaline urine; chyle in the urine; fibrin in the urine. 



REFERENCE TABLES. 47 

B. Diminished consistency, shown by increase in the froth- 

iness. — Albumin or sugar in the urine. 

Frothiness is increased sometimes in urine of high specific grav- 
ity; in urine feebly acid or alkaline; in urine containing excess 
of mucus. 



REFERENCE TABLE 9. 
Appearance of the Urine. 

A. The urine looks milky. — In children, perhaps due to sed- 
imen' of urates, cleared by heating; due to presence of pus, or 
chvle. 

B. The urine has a greenish-red 'smoky" hue.— Suspect 
piesence of blood in it. 

C. The urine has a dusky hue. — See remarks on brown and 
black color. 

D. The urine is turbid when freshly voided.— Suspect pres- 
ence of blood, bile, mucus, pus, phosphates. If light color, the 
last three; phosphates cleared by shaking with 50 per cent, acetic 
acid. Pus, blood, and mucus are not cleared by the acetic acid. 

E. The urine is clear when freshly voided, but becomes 
turbid on cooling. — A sediment of urates has deposited and may 
be cleared by heat (150° F.) 

F. The urine is turbid, and, when shaken, the cloudiness 
has a wave-like motion. — Presence of bacteria in the urine. 
Not affected by acetic acid. The urine never clears completely 
on standing. 

G. The urine niters slowly. — Excess of mucus; presence of 
pus, blood. 



48 



URINARY ANALYSIS. 



CHAPTER Y. 



EXERCISES IN PHYSICAL CHARACTERISTICS. 

The student having collected his twentv-four hours' 
urine day and night separately, measured it, and 
mixed it, should determine the physical characteris- 
tics as follows : 

CHEMICAL EXERCISE II. 

A. Filter the urine:— Obtain glass 
funnels {Fig. £), filter paper, of the 
size represented in Fig. 7, filter rings 
and stand {Figs. 8 y 9, 10 show dif- 
ferent kinds) and collecting vessels, as 
wide mouthed bottles or beakers. 

Fig. 11 shows a convenient appara- 
tus for managing filtration. The 
receiving vessels in Fig. 11 are beak- 
ers, which are sold in " nests " {Fig. Fig. 6. g'^s fun- 
12) of different sizes. nel used in fil- 

x^ iiiiT „ tering urine. 

X unnels should be of two sizes (a) those 3 or 4 inches 
m diameter across the top, and (b) those about two 
inches. The smaller ones may be set directly into 
test-tubes. The larger ones require either a support 
or a w T ide-mouthed bottle to rest in. 





Fig. 11. Apparatus for filtration. 



CHEMICAL EXERCISES. 



49 




Fig. 7. This circle represents the exact size (4 inches diameter) of 
filter paper most convenient for use in these exercises. 

Filter- pa per should be bought already cut in pack- 
ages of 100. For the larger funnels get paper about 
T-J inches in diameter. For the smaller funnels use 
the size shown in Fig. 7. The larger funnels and pa- 
per are useful for various quantitative filtrations, as in 
uric acid determinations ; the smaller ones for qualita- 
tive work, especially clinical. 

For the larger funnels buy what is known as rapid 
filtering paper, which is especially serviceable when 
it is desired to collect sediments on a filter. 

For filtering urine dear do not use rapid filtering 
paper, but fold several of the smaller papers together. 
4 



50 



URINARY ANALYSIS. 



In order to fold filter-paper, first fold it in two, 
then fold again in two, but this time at right angles 
to the first folding. A funnel shape is thus given to 
it, and it may be fitted into a funnel and is ready for 
use. 




Fig. 12. "Nest" of beakers. 



Filter the urine into a thin glass jar or beaker at 
least 3 or 4 inches in diameter, and for observing color 
always use the same beaker. Observe whether the 
urine filters slowly or rapidly. If it filters slowly, it 
indicates the presence of mucus in excess. 

Note whether the color is normal (straw-yellow), 
pale, or high. More precisely, compare the shade 
with Yogel's Color Scale, and report the color as No. 
1, 2, or 3, etc., on this scale. Note any unusual color 
as red, green, brown, or black. 

Yogel's Color Scale divides the urinary colors into 
the following : — (see Frontispiece). 

1. Pale-yellow ; — 2. Light-yellow ; — 3. Straw-yel- 
low ; — 4. Red -yellow ; — 5. Yellow -red ; — 6. Eed ; — 
7. Brown-red; — 8. Eed-brown; — 9. Brownish-black. 

These colors, as given us, seldom match closely with 
the color of the filtered urine. Between yellow-red 
and red, as pictured in the books, a number of urine 
shades occur. Moreover the colors in the color-scale 



CHEMICAL EXERCISES. 51 

fade on exposure, so as to show in time but little dif- 
ference in the first three shades. As yet, however, 
nothing superior to this scale has been devised. The 
author has been able to imitate closely several of the 
urine tints by solutions of certain chemicals, as, for 
example, a peculiar dark inky-red by diluting oxychlo- 
ride of iron solution. 

B. Smell of the urine and note whether the odor is 
slightly (a) aromatic, not at all unpleasant, sometimes 
agreeable; (b) strongly aromatic, still not disagreeable, 
as in fevers ; (c) pungent, slightly disagreeable, as in 
case of urine twenty-four to forty-eight hours old ; (d) 
fetid, decidedly unpleasant, suggesting decomposition ; 
or (e) ammoniacal, having distinct odor of ammonia. 
(Students are usually at fault regarding the odor of 
urine.) 

Note whether there is any odor of ox-gall (bile), or 
of any drug, such as cubebs, sandalwood, creasote, etc. 

C. Take the specific gravity of filtered urine in the 
beaker, pouring it carefully, to avoid foam, into the 
fluted jar which comes with Squibb's urinometer, 
removing foam with filter paper. When the urinom- 
eter is floating in the liquid, touch the top of the stem 
lightly so that it sinks and rises a few seconds, then 
wait until it settles down to quietude. Kead off the 
scale when on a level with the eye, and note the figure 
on the level of the liquid. For accurate work use a 
chemical thermometer, and warm or cool the urine to 
77° F. (25° C), by setting the jar in hot or cold 
water. 

D. Compute the total solids by multiplying the 
number of cubic centimeters of urine in twenty-four 
hours by the last two figures of the specific gravity, 
that product by 2.33, and divide last product by 1,000. 
The result is grammes of total solids for twenty-four 
hours. Convert to grains by Table 3, Appendix. 
Compare the number of grains found with what the 
student ought to excrete for his age and weight, using 
Table 3 in Appendix. 

E. Work out the following problems in total solids : 



52 URINARY ANALYSIS. 

(a) Urine in twenty-four hours. 850 c.c. ; specific gravity, 1012; 
age 55, weight 160, fasting, in bed. How do->s the excretion com- 
puted compare with the theoretical excretion based on 945 grains 
(61 grammes) minus the deductions for age. etc. 

ib) Urine in twenty-four hours. 400 c.c; specific jrravity. 1020; 
age. 70; weight. 155; appetite and diet normal; exercise, normal. 

(c) Urine in twenty-four hours, 1500 c.c; specific gravity, 1025; 
age, 30; weight, 140; otherwise normal. 

F. Take the reaction of the urine with litmus 
paper, holding two slips, reel and blue, in the urine 
until saturated, or placing a drop of urine in the 
center of each of the slips. If the blue paper is turned 
red and no change has taken place in the red paper, 
the urine is acid. Notice whether the reddened lit- 
mus is only slightly reel, or a bright brick-red, i. <?., 
feebly acid or strongly acid. If neither paper is 
affected in color, the urine is neutral. If the red 
paper is turned blue and no change takes place in the 
blue paper, the urine is alkaline. Let the paper, 
which has been turned blue, dry; notice whether it 
remains blue (fixed alkali) or turns red again (volatile 
alkali). 

If both the blue paper is turned red and the red 
paper blue, the urine is what is called amphoteric in 
reaction, which is without known significance. 

Acid urine 'on standing sometimes becomes more 
acid than normal, due to action of mucus as a ferment 
producing a lactic fermentation, darkens in color, and 
deposits a sediment (uric acid and urates), calcium oxal- 
ate, penicillium glaucum (fungi) and bacteria, so that the 
reaction should be taken as soon as possible after the 
twenty-four hours are up. Again, in the course of 
three or four days, usually, or sooner in hot weather, 
the urine grows turbid from the presence of micro- 
organisms, becomes alkaline from decomposition of 
the urea, which is converted into ammonium carbonate 
by action of the micro-organisms, and a whitish phos- 
phatic sediment is deposited. 

Note. — Despite the assertions of some authors it is possible to 
have a sediment of uric acid and triple phosphate in the same 
sample of stale urine. The writer has seen it occur several times. 
As the urine becomes hyper-acid uric acid crystals are deposited, 
and these may not be entirely dissolved after the alkaline change 
has caused deposit of triple phosphate. 



CHEMICAL EXERCISES. 53 

G. Note the appearance of the unfiltered urine, 
whether clear or turbid. If turbid, set a few ounces 
aside and, after a time, a sediment or deposit will be 
noticed. Students sometimes incorrectly report "no 
sediment" in urine which they have previously 
described as " turbid ". Note whether the turbidity 
is slight, slowly settling, as in case of almost all normal 
urine twenty-four hours old, or whether the urine is so 
turbid as to deposit an abundant sediment within half 
an hour or so. 

When the urine of women is examined, a whitish 
sediment of mucus is almost always noticed. 

H. Note the consistency of the urine, whether it 
flows easily, or is thick and ropy from presence of 
muco-pus; or creamy, forming a jelly-like mass on 
standing, due to chyle or fibrin. 

I. Shake some of the urine in a bottle, and notice 
whether the foam subsides quickly, or whether it is 
wholly permanent. 

J. Make out a report filling in the following blanks : 

1. The urine filters (Specify whether slowly 

or rapidly.) 

2. Color of the filtered urine 

3. Odor -.., suggesting 

4. Specific gravity at 77° F. (25° C.) 

5. Total solids by Hasser's coefficient _ grammes; 

grains. 

6. Corrections for age, weight, diet, and exercise leave a total 
of grammes; grains of solids. 

7. The patient should void by Table 3, Appendix, and correc- 
tions grammes; grains of solids. 

8. Therefore this patient is voiding compared 

with what he or she ought to void. 

9. Reaction 

10. Appearance 

11. Consistency 

12. Frothiness 



Apparatus used in Chemical Exercise 2. 

1. Glass funnels, some 2 inches, others 3 or 4 inches in diameter 
across the top. 2. Slips of blue and of red litmus paper or litmus 
pencils. 3. A filter ring and stand. 4. Filter papers, ordinary 
and for rapid filtering. 5. Glass beakers. 6. Vogel's color scale. 
7. Squibb's urinometer and fluted jar. 8. A chemical thermome- 
ter. 



54 URINARY ANALYSIS. 



CHAPTER YI. 



NORMAL CONSTITUENTS OF URINE : UREA. 

The normal constituents of urine of clinical interest 
are the following : 

A. Organic, -j Tj^acid and urates. 

5 Phosphates; 
Chlorides; 
Sulphates. 

In addition to these there are numerous other sub- 
stances of less clinical importance which will be de- 
scribed with less detail than in case of the above. 

UREA. 

Pronunciation: TJ'rea. 

Synonyms: German, Hamstoff; French, Uree., 

Chemical constitution: CH 4 1S T 2 0, or CO j ^ H 2 

carbamide, an amide of carbonic acid ; an organic sub- 
stance, containing over 45 per cent, of nitrogen. 

Occurrence: Always in solution in urine of any 
reaction. Never in the sediment of urine. Urine is 
a solution of urea in strength about 2 per cent. 

Form: Crystalline ; quadratic prisms. 

Color and appearance: Pure urea occurs in com- 
merce in colorless crystals, of taste like saltpetre. 

Solubility: 1. Keadily soluble in water and alco- 
hol. 2. Insoluble in ether and chloroform. 

Reaction: Solutions of urea are neutral in reaction. 

Preparation: (a) From the urine by evaporating 
the latter to syrupy consistence, adding gradually and 
with constant stirring pure nitric acid in excess ; ni- 
trate of urea crystallizes out, from which, when sepa- 
rated, urea may be obtained by decomposition with 



NORMAL CONSTITUENTS OF URINE: UREA. 



55 



barium carbonate, (b) Synthetically by heating am- 
monium cyanate to 100° C. (212° F), (Wohler, 1828); 
(c) By the action of ammonia on carbonyl chloride. 
Note: The equations in the two processes in (b) are as follows: 

1. CNONH 4 = CO -J NH 2 by molecular rearrangement. 

2. COCl a +4NH 3 =CO (NH 2 )$+2NH 4 C1. 

Miscellaneous properties: The crystals of urea 
contain no water of crystallization ; they are perma- 
nent in the air. The commercial article in time gives 
off an odor of ammonia, due to change into ammonium 
carbonate, which occurs by taking up water, as under 
the influence of a ferment, as follows : 

CH 4 N 2 0+2H 2 0=(NH 4 ) 2 C0 3 . 
(Urea.) (Water.) (Ammonium carbonate,) 

This change may take place in the bladder under 
the influence of bacteria, the micrococcus urece, to be 
explained further on. 

The ammoniacal odor of decomposed urine is due to 
this change into ammonium carbonate. 

Combinations: (a) With nitric acid, forming urea 
nitrate; (b) with oxalic acid, forming urea oxalate 
— 2.CO(NH 2 ) 2 .H 2 C 2 0^. Also, combinations with 
mercuric nitrate in variable proportions, one of which 




Fig. 13. Crystals of urea. (Purdy.) 
serves as a basis for Liebig's titration method, and 
with various salts, as sodium chloride, and chlorides 



56 



URINARY ANALYSIS. 



of the heavy metals, forming combinations, for the 
most part crystallizable. 

Microscopical appearances: Urea itself: Silky, 
four-sided prisms with oblique ends, or (rapidly crys- 
tallized) in delicate white needles {Fig. 13). Nitrate of 
urea: Thin rhombic or hexagonal crystals, overlap- 
ping tiles, colorless plates, whose point has an angle 
of 82° {Fig. H). Larger and thicker rhombic pillars 




Fig. 14. Crystals of urea-nitrate. 
{Krukenberg.) 



or plates are obtained on slowly crystallizing. Oxal- 
ate of urea : Ehombic or six-sided prisms or plates 
more regular than the nitrate. {Fig. 15.) 




Fig. 15. Crystals of urea-oxalate. 

{Krukenberg.) 



NORMAL CONSTITUENTS OF URINE: UREA. 57 
MICRO- CHEMICAL TESTS. 

1. To a drop of urine, preferably of high specific 
gravity, on a glass slide, add a drop of nitric acid ; 
warm it gently and cautiously over an alcohol lamp 
until it is slowly evaporated. Characteristic crystals 
of urea nitrate may be seen under the microscope even 
with a low power, 150 diameters. {Fig. ll/,.) 

2. Again, place a drop of urine, preferably of a 
high specific gravity, on the slide, add a thread 
and cover-glass, and allow a drop of nitric acid 
to enter by capillarity. Crystals of the nitrate 
of urea will form along the thread. 

CHEMICAL TESTS. 

A. Qualitative. 

1. The biuret reaction: Heat crystals of urea in 
a test tube; the crystals melt, decompose, give off an 
odor of ammonia, leave a whitish residue which, dis- 
solved in water, to which a couple of drops of sodium 
hydroxide solution (caustic soda) and a drop of a dilute 
solution of copper sulphate being added, a violet or 
rose-red color is produced. 

2. The furfurol test: Treat a crystal of urea with 
a drop of a nearly saturated solution of furfurol in 
water, and immediately with a drop of hydrochloric 
acid (sp. gr. 1.1); a color-change occurs, passing from 
yellow through green, blue, and violet to purple-red. 

3. Decomposition with solutions of alkaliue hypo- 
bromites or hypochlorites. 

B. Quantitative. 

Detenu inatiou of urea (theoretical). The prin- 
ciple on which our clinical* quantitative determina- 
tions are founded is that urea is decomposed by hypo- 
bromites, with formation of carbon dioxide and nitro- 
gen. In practice we use an alkaline hypobromite, as 
sodium hypobromite, since carbon dioxide (carbonic 
acid gas) is soluble in alkalies, while nitrogen is insolu- 
ble. The urine is introduced into a graduated tube, 
filled with the chemical solutions, and the nitrogen 



*The Liebig method is described in the Appendix. 



58 UBINARY ANALYSIS. 

gas evolved collects at the top of the tube and dis- 
places the solution. 

The equation is as follows : 

CH 4 N 4 0+3NaBrO.=N 2 +C0 2 +2H s O+3NaBr. 

In other words, urea plus soclic hypobromite, equals 
nitrogen plus carbonic dioxide, plus water, plus sodic 
bromide. From this it may be calculated that 60 
parts of urea by weight (the sum of the atomic weights 
of the atoms in the molecule CH 4 N 2 0) yield 28 parts 
of nitrogen by weight. One gramme of urea, then, 
would yield 28-60 gramme of nitrogen, which is known 
to occupy a volume of about 371-J- cubic centimeters. 
If, then, 371-J- c.c. of nitrogen gas indicates the pres- 
ence of one gramme of urea in a given quantity of 
urine, then one c.c. of nitrogen gas would indicate the 
presence of one divided b} T 371^ which equals 0.002(19 
gramme of urea. Every c.c, of nitrogen gas obtained 
in the process at ordinary temperature and pressure 
signifies that 0.00269 gramme of urea is present in the 
amount of urine used, and on this principle the grad- 
uation of the instruments is made. In some American 
instruments the French measures are not used but 
American grains per ounce instead. Grammes per 
liter may be converted into grains per ounce by divid- 
ing by 2-§-. _ 

The clinical instruments for determination of urea 
which are most commonly used are those of Hartley, 
Doremus and Squibb. The method by which we de- 
termine the quantity of urea in the urine is given in 
full in the next Chemical Exerecise, where the three 
instruments are described. 



PROPERTIES AND REACTIONS OF UREA, 



CHAPTER VII. 



PROPERTIES AND REACTIONS OF UREA. 



CHEMICAL EXERCISE III. 

A. Properties and Reactions of Urea. 

B. Quantitative Determination of Urea. 

C. Calculation of Results. 

Properties and Reactions of Urea. 

1. Examine crystals of urea. Note col- 
or, taste, solubility in water and alcohol ; ac- 
tion of hot alcohol; of ether, and of chloro- 
form. 

2. Take the chemical reaction with lit- 
mus paper of an aqueous solution of urea. 

What is it? 

3. Perform the biuret test, as follows : — 
Fuse about 0.3 gm. (5 grains) of urea in a 

test-tube, shown in Fig. 16. Now boil the 
liquefied crystals till a white residue appears ; 
next add about 10 c.c. (2 to 3 fluidrachms) 
of distilled water, shake thoroughly and add 
several cubic centimeters (1 to 2 fluidrachms) 
of a strong solution of sodium hydrate (10 
gm. in 25 c.c. water, or 155 grains to the 
fluiclounce). Fl Test 16 ' 

Set the tube aside for the present. Now Tubes, 
make a solution of cupric sulphate in distilled water, 
strength 0.5 gramme (3 grains) to 100 c.c. (3£ fluid- 
ounces.) Add several drops of this copper solution, 
drop by drop, to the alkaline solution above made, and 
a beautiful red -violet color appears at the top. Too 
much or too strong copper solution gives a blue color 
with the alkali, which can be seen by adjing a large 
number of drops of the copper solution. 



60 



URINARY ANALYSIS. 



In this test urea is converted into biuret, or allo- 
phanamicle, a derivative of urea. 

4. Perform the furfurol test as follows : Shake up 
one c.c. of furfurol with about 15 c.c. of water. To 
a crystal or two of urea on a porcelain surface add a 
drop of the furfurol solution and immediately a drop 
of strong hydrochloric acid, and observe the color 
change, in which a purplish tint is prominent. Fur- 
furol is an expensive article, and waste should be 
avoided. 
Quantitative Determination of Urea (Practical). 

1. The student having collected, mixed, 
and measured his twenty-four hours' urine, 
should proceed to determine the quantity of 
urea by use of Bartley's ureometer, and Leslie 
Bee be 's clamp {Fig 17.) 

Bartley's ureometer consists of a somewhat 
long, graduated tube, called by chemists a 
" gas tube," and a 1 c.c. pipette, about 
twice the length of a medicine-dropper, with 
a rubber nipple on one end of it. That is the 



To estimate urea with 
is only necessary to pro- 
graduated tube up to the 
twenty per cent, solution 
bromide (bromide of pot- 



entire apparatus, 
this instrument it 
ceed as follows : 

1. Fill the long 
mark five with a 
of C.P. potassium 
ash). 

2. Next, pour in a solution of Squibb's 
chlorinated soda up to the eighteenth mark, 
or anywhere between the eighteenth and 
twentieth mark on the tube. [In buying the 
chlorinated soda solution, get Squibb's 2 per 
cent. U. S. P., put up in sealed bottles con- 
taining 250 grammes. The solution does not 
keep long after the bottle is opened, hence it 
is better to get six 250 gramme bottles, 
rather than one large one.] 

3 



Fm. 17. 
Leslie 
Beebe's 
clamp. 

Let water trickle slowly down the side of the tube 



till the latter is filled to the twenty-fifth mark. 
,4. Now take up urine with the pipette exactly to the 



PROPERTIES AND REACTIONS OF UREA. 61 

single mark on this little instrument. Some practice is 

necessary in order to do this well. See that the rubber 

nipple is not cracked. It is well to buy a few dozen 

pure gum rubber nipples, but care roust be taken that 

they fit tightly to the large orifice of the pipette. 

In order to take up urine in the pipette exactly to 

the mark on the pipette, dip the latter below the level 

of the urine, squeeze the rubber nipple, then gradually 

relax pressure and the urine will rise in the tube. 

Keep the tip end of the pipette below the level of the 

urine always so that no air bubbles shall rise, and 

keep trying till finally you have the urine exactly to 

the mark. Relax all pressure on the nipple when this 

has been obtained — but it is best to relax gradually so 

that by the time all pressure is relaxed the urine has 

risen to the mark. 

Note. — By use of a soft rubber nipple 1 c.c. of urine can be 
easily obtained as follows: Draw up more than one c.c. into the 
pipette and then work the nipple down. The urine flows out as 
the nipple is worked downward, and no air-bubbles euter from be- 
low. Work the nipple down until the level of the urine is exaccly 
that of the 1 c.c. mark, then take the pipette by the glass por- 
tion, avoiding pressure on the nipple, and introduce it into the 
Bartley tube. 

5. Now hold the long tube well inclined in the left 
hand and with the right cause the urine in the pipette 
to trickle slowly down into the liquids in the long tube, 
squeezing the rubber very gently. When all the 
urine has been squeezed out of the pipette, gradually 
raise the inclined long tube to the perpendicular and 
put Beebe's clamp over the mouth of the tube. In- 
vert the long tube several times. Inside the tube the 
urine mixes with the chemicals and a lively efferves- 
cence takes place. Nitrogen gas has been set free by 
the action of the chemicals on the urea and is trying 
to escape from the tube. Now bring the tube to the 
perpendicular position, and wait for the effervescence 
to cease. This may take several minutes. Read what 
mark on the tube is even with the level of the liquid 
in the tube after the foam has settled. You will see 
the figure 15 without difficulty somewhere near the 
level of the liquid in the tube. The next long mark 
not lettered is 16, the next 17, the short marks 



(52 



URINARY ANALYSIS. 



between the long ones representing quarters. 
If, then, the level of the liquid is one long mark 
plus two short ones below 15, then the level is 
at sixteen and a half. Having made the read- 
ing accurately, carry the instrument to the 
nearest jar (Pig. 18.) filled with water, and 
plunge the instrument below the level of the 
water. When once below the water's edge, 
remove the clamp and notice that instantly 
the level of the liquid in the tube sinks. This 
is because the pressure of the clamp being re- 
laxed the nitrogen gas is able to expand to its 
proper bulk, which it does, driving out the 
liquid as it does so. Now see that the level 
of the liquid inside the tube is the same as the 
water outside, raising or lowering the tube ? G " f 18 ' 
as necessary, but always keeping its mouth use in 
under water. Wait three minutes for diffu- Bartley's 
sion to take place. Then take a second read- P rocess - 
ing. The level of the liquid will now be down any- 
where from the twentieth to the twenty-fifth mark, in 
exceptional cases from the nineteenth to the thirtieth. 
Subtract the first reading before the clamp was removed 
from the second reading, after the clamp was removed, 
and the difference represents grains of urea in one fluid- 
ounce of the urine under examination. For example, 
if, after the effervescence has ceased, and the clamp 
is still over the mouth of the tube held perpendicularly, 
mouth clown, the level of the liquid inside is at the 
sixteen-and-a-half mark, and if, after you have plunged 
the instrument under water and taken away the clamp 
the level of the liquid is now at the twenty -six-and-a- 
half mark, then twenty-six-and-a-half minus sixteen- 
and-a-half equals ten, that is, ten grains of urea in 
every fluidounce of the urine. 

If you are working with the twenty-four hours' 
urine, as you ought to be, then multiply the ten, or 
whatever figure you get, by the number of fluidounces 
of the urine in twenty-four hours ; that is, if there are 
fifty fluidounces of urine in twenty-four hours, and ten 
grains in every fluidounce, then you have 500 grains 



PROPERTIES AND REACTIONS OF UREA. 63 

of urea in twenty -four hours. If you have, say forty 
fluidounces, and the difference in the readings is seven, 
then seven times forty, or 280 grains, in twenty-four 
hours. [To convert grains per ounce to grammes per 
liter, see Table h Appendix. Grains total to grammes, 
Tabled.'] 

The whole operation is simple, and takes less time 
to perform than to describe. I recently distributed 
Bartley's ureometers to a class of fifty or sixty stud- 
ents who had never before used them, and the results 
of the first trial in ninety per cent, of the cases were 
sufficiently near my own to be "clinically accurate." 
After three or four trials there were but one or two 
who did not obtain the correct results. The only pre- 
cautions of importance are : — 

1. To see that the urine is taken up exactly to the 
mark on the pipette ; 

2. That the clamp is not removed until the orifice 
of the instrument is under water. 

The advantages of Bartley's instrument when provided with 
Leslie Beebe's clamp are the following: 

1. Bromine is not used. 

2. The instrument is not easily broken, and can be hung up on 
a peg or nail. 

3. The decomposition of the urea within the tube takes care of 
itself, does not need to be watched nor helped. 

4. The urine, if of high specific gravity, does not need to be di- 
luted. 

5. Rubber tubing is dispensed with. 

The advantages of the Leslie Beebe clamp are: 

1. The instrument, thus closed, may be hung up on a nail, and 
the physician attend to other business while the decomposition is 
going on. 

2. A tall narrow glass cylinder full of water may be used, and 
the reading easily taken when the clamp is removed. 



64 



URINARY ANALYSIS. 



CHAPTEE VIII. 



THE DETERMINATION OF UREA BY OTHER CLINICAL 
METHODS. 



One of the most popular clinical instruments for de- 
termination of urea is that of Dr. Doremus, of New 
York. No modern book on clinical urinary analysis 
is complete without a description of this apparatus. 



grammes 



Q 



Doremus' instrument. {Fig. 19.) One hundred 
(1,543 troy grains) of caustic soda dissolved in 
250 c.c. (8.5 fluidounces) of distilled water. Of 
this solution take 10 c.c. (2.7 fluidrachms) and 
add 1 c.c. (16 minims) of bromine. Shake the 
mixture well, until the bromine is dissolved 
and the whole becomes yellow in color. Di- 
late with 10 c.c. of water. Pour the whole 
into the cup of Doremus' ureometer and care- 
fully fill the limb with it by tipping backward. 
Then by means of the curved pipette introduce 
1 c.c. of urine into the soda solution. Ef- 
fervescence takes place and the soda solution is 
displaced by the gas formed. 

The instruments are graduated either in 
grains per ounce or in grammes per liter. In 
the latter case the figures 0.01, 0.02 and 0.03 sig- 
nify 10 gm., 20 gm. and 30 gm. per liter, respect- 
ively. See Table If., Appendix, for conversion 
to grains per ounce. 

Manipulation. 

1. Get Larkin & Scheffer's bromine, as the 
bottles are easier to open. Use great care in 
opening the bottles. -& -m t\ > 

2. Use the 1 c.c. pipette in adding bromine to * 
the caustic soda solution. 

3. Dilute all urines of specific gravity 1025 




ureometer, etc. 
with foot. 



or upwards with equal parts of water and multiply result obtained 
by 2. 

CLINICAL NOTE. 



The writer has made several thousand determina- 
tions of urea with the Doremus instrument, and can 
commend it for simplicity. It is not as durable as the 
Bartley, but does not involve the use of rubber tubing. 



DETERMINATION OF UREA. 65 

The principal objections to it are the use of bromine, 
and the necessity for diluting the urine in cases where 
the specific gravity is above 1025, since the gas, when 
in excess, drives the hypobromite solution below the 
graduation. Again, unless the instrument is provided 
with a foot, it is without support and, when it is made 
with a foot, it is easily broken. After the foot is 
broken insert the broken end into paraffin, melted in 
a tin box or other receptacle and allowed to solidify. 

The great advantage of the Doremus instrument, to 
the author's mind, consists in the use of hypobromite, 
which may be freshly made for each determination. 
But few will agree with him from a practical stand- 
point, since use of bromine is exceedingly unpleasant 
to the majority. An important practical point in the 
use of bromine is the fact that Larkin & Scheffer put 
up bromine in such a way that it is possible to get the 
glass stopper out of the bottle with comparatively lit- 
tle difficulty. Novices who break bottles of bromine 
with dangerously unpleasant results will do well to 
note the above. 

Too large quantities of hypobromite should not be 
made, as it deteriorates on keeping, though not in a 
week's time, as I have often observed. How much 
longer it will keep I do not know. Again, some 
samples of bromine combine with the sodium hydrox- 
ide solution with more energy than others. The 
writer once shook up 10 c.c. of bromine with 100 c.c. 
of caustic soda solution, with result that the bottle 
burst and was broken to atoms, either from the heat 
generated or for other reasons. It is safer in making 
100 c.c. to make 10 lots of 10 c.c. caustic soda solu- 
tion containing 1 c.c. of bromine each. 

The Squibb apparatus (Fig. 20) consists of three bottles con- 
nected during the determination by rubber tubing. Into one of 
the bottles standing upright a short test tube, F, containing a 
measured volume of the urine is dropped by means of a small for- 
ceps. A bent glass tube and a rubber tube connect this with the 
other bottle, B, which, at the beginning of the test, is quite filled 
with water. Another glass tube connects B with the bottle D, 
empty at the beginning of the test 

To make the test, pour into the first bottle 20 c.c. of strong hy- 

5 



60 



URINARY ANALYSIS 



pobromite solution, or 40 c.c. of the hvpnchlorite. Measure accu- 
rately 4 or 5 c.c. of urine into the tube, drop this into the bottle 
and insert the stopper. Fill B quite full of water, and insert its 
stopper which drives out a little water through the short tube 
into D. Allow the whole apparatus to stand ten minutes to take 
the temperature of the air, then empty D and replace it. Now 
tip the first bottle so as to mix the contents of F with the reagent 
and shake gently. Babbles of gas escape and parsing over into B 
drive out a corresponding volume of water. Repeat the shaking 
of the reagent bottle several times. In a few minutes the reaction 







Fig. 20. 



Squibb's apparatus for determination 
of urea. 



is complete, but the apparatus must be allowed to stand to cool 
down to the air temperature. A part <>f the water in D may be 
drawn back into B. Finally measure the volume of water left in 
D, and take this as the volume of gas liberated. Make the calcula- 
tion as before on the assumption that each c.c. of gas corresponds 
to .0027 Gm. of urea. 

The results obi med are said to be more accurate than those 
where but 1 c.c. of urine is used. 

CLINICAL NOTE. 

The Squibb apparatus is unpopular with most stud- 
ents and physicians, who prefer a more ready method, 
even if the results obtained are not so accurate. 

The principal objection, in the writer's mind, to 
Squibb's apparatus is the use of small rubber tubing 
which, in time, wears out and must be replaced. The 
instrument is, however, certainly to be commended to 
those who have time and opportunity for more careful 
clinical determinations. 
Error of the clinical instruments: 

It must not be assumed that the clinical instruments 
are chemically accurate in the results shown. When 



DETERMINATION OF UREA. 67 

the quantity of urea in the urine is small, two to four 
grains per ounce (1 to 2 gm. per liter), the error is 
small, but when the percentage of urea is high, 10 to 
15 grains per ounce, the error is considerable. Drs. 
Bader, Hollo way, Leslie Beebe, and the writer have 
conducted numerous experiments for information on 
this point. The results have been as follows : 
Bartley gas tube: 

Solution of urea 9-J- grains per ounce ; five determi- 
nations with the Bartley instrument and Leslie Beebe 
clamp gave 10 grains, 10J, 10J, 10J, 10-J- respec- 
tively. Error, one-half grain to a grain per ounce, 
too high. 

Solution of urea 4f grains per ounce : Bartley gave 
5f grains. Error about two-thirds grain per ounce 
too high. Another determination, 51-5 grains, about 
a half grain too high. 

Solution of urea 15f grains per ounce : Bartley gave 
14 grains per ounce, or one and two-thirds grains too 
low. 
Dorenius' instrument: 

Solution of urea 4.7 grains per ounce: Doremus' 
instrument 4 grains per ounce, or about three-quar- 
ters of a grain too low. 

Solution of urea 15f grains per ounce: Doremus' 
instrument, 11-J- grains per ounce, or about 4 grains 
per ounce too low. 

Now, while these errors, from a chemist's view- 
point, are great, clinically we have not much cause to 
complain, for the following reasons : 

1. In cases in which urea is low in grains per ounce 
the error is usually but a fraction of a grain. Suppose 
it be a whole grain. If the patient passes 50 ounces 
of urine, the total error is at most 50 grains in, say, 
200 to 300 grains total of urea per 24 hours. In cases 
where the patient voids 80 or 100 fiuidounces of urine, 
the total error is not correspondingly increased since 
the quantity of urea in grains per ounce will be less, 
and the error less per ounce. 

2. In cases where the urine is concentrated and the 
error 2 to 4 grains per ounce, the total error is likely 



68 URINARY ANALYSIS. 

to be no greater, if as great as above, because the 
quantity of urine per 24 hours will be small. More- 
over, by diluting the urine in these cases with equal 
parts water, as is of necessity done when the Doremus 
instrument is used, the error is not as great. 

I conclude, therefore, that the clinical methods en- 
able us to determine the total quantity of urea present 
within 25 or 50 grains at most, which in anything 
above 100 grains is of no great importance. In gen- 
eral, any quantity of urea below 200 grains in 24 hours 
is small, and above 450, large, unless in the latter case 
the patient be a large, heavy person. If the patient 
is passing less than 300 grains, it should attract our 
attention. The clinical instruments certainly enable 
us to determine these points, and also to judge in a 
general way whether the elimination of urea is increas- 
ing or decreasing to a marked extent. 

C. Calculation of results: 

BARTLEY INSTRUMENT. 

1. Subtract the reading made before immersing in 
water from that made after the Beebe clamp is removed 
under water. The difference is grains of urea in fluid- 
ounces of urine. Convert into grammes per liter by 
Table h Appendix, and find out also by this table what 
per cent, of the normal average it is. 

2. Multiply the grains of urea per ounce by the num- 
ber of fluidounces of urine in 24 hours. Product rep- 
resents the total grains of urea in the 24 hours' urine. 
Convert into grammes per 24 hours by Table 5, Appen- 
dix, and find out also by this table what per cent, of 
the normal average it is. 

3. Determine what per cent, of the weight of the 
twenty-four hours' urine the urea for twenty-four 
hours is, (so-called percentage of urea in the urine; 
carefully distinguish from per cent, of normal aver- 
age.) To do this divide the grammes per liter found 
in 1 by 10. The result is approximate only, since the 
specific gravity of the urine is disregarded. 

Examples: 

1. Male patient passes 40 fluidounces of urine in 24 hours: 



DETERMINATION OF UREA. 69 

Beading before immersion, 16; after, 25. (40 fl. oz. equals about 

1200 c.c). 

Answers: 

(a) 25 minus 16 equals 9 grains per ounce; 

(6) 9 grains per ounce by Table 4 equals 19.85 grammes per liter; 

(c) 9 grains per ounce or 19.35 gm. per liter in a male {Table 4) 

equals 90 per cent, of the normal average; 

(d) 9 times 40 equals 360 grains urea in 24 hours; 

(e) 360 grains by Table 5, Appendix, equals about 23 grammes; 
(/) 360 grains, or 23 gm. in a male equals by Table 5, 90 per 

cent, of the normal average; 
(g) 19.35 gm. per liter (b) divided by 10 equals 1.93 per cent, of 

urea in the 24. hours' urine. 
2. Female patient voids 66 fluidounces of urine in twenty-four 
hours: the reading before immersion is 15f , after immersion it is 19. 

(a) 19 minus 15% equals 3 1-4 grains urea per ounce urine; 

(b) By Table 4, Appendix, 3£ grains per ounce equals about 6.4 
gm. per liter; 

(c) By Table 4, Appendix, 3£ grains per ounce or 6.4 gm. per 
liter, equals about 35 per cent, of the normal average in 
case of females; 

(d) 3% times 66 equals 215 grains urea in 24 hours; 

(e) By Table 5, 215 grains ^ quals about 14 grammes; 

(/) By Table 5, 215 grains or 14 gm. in females equals 70 per 

cent, of the normal average ; 
(g) 6.4 gm. per liter (6) divided by 10 equals 0.64 per cent. 

(sixty-four hundredths of one per cent.) of urea in the urine # 

REPORT. 

Make out a report as follows : 

Urine per 24 hours, c.c fl. oz 

What per cent, of normal for sex.._ 

Urea, grains per ounce 

grammes per liter 

What per cent, of normal for sex 

Urea, grains per 24 hours 

grammes per 24 hours 

What per cent, of normal for sex 



Chemicals and Apparatus Used in Chemical Exercise III. 

An ounce of urea crystals. 

Distilled water. — Alcohol. — Ether. — Chloroform. 
Litmus paper. 

Solution of sodium hydroxide, 100 grammes in 250 c.c. of water. 
Solution of cupric sulphate, one-half of one per cent. 
Solution of furfurol, nearly saturated. 
Hydrochloric acid, c.p., U. S. P. 
Nitric acid, c.p., U. S. P. 
Strong solution of oxalic acid. 

One dozen five-inch test-tubes, with test-tube, rack, (Fig. 21.) 
Bartley's urea instruments. 
Leslie Beebe's clamps. 

Tall narrow jars, preferably 10 or 12 inches high and 2 or 3 inches 
in diameter; in default of these any container of this size or larger. 
Test-tube cleaner. 



70 



URINARY ANALYSIS. 




Fig. 21. Test-tube cleaner. FlG. 22.— Test-tube rack. 

Alcohol lamp (Fig. 22), or Bunsen burner. (Fig. 24.) 





Fig. 23, Alcohol Lamp. 

Fig. 24. Bunsen Burner. 
Glass slides. 

Solution of potassium bromide, c.p., freshly made. 20 per cent. 
Squibbs' solution of chlorinated soda, in amber b >ttles, with 
rubber stoppers, containing: 250 grammes. 

[Standard methods for determining urea, and total nitrogen, 
are given in the Appendix.] 

microscopical exercise I. 

1. (a) Dissolve some crystals of urea in water, warm 
a few drops of the solution on a glass slide, and exam- 
ine with a low power (150 diameters) and subsequently 
with a high power (500). Make a drawing in a note- 
book, of the crystals seen, (b) Dissolve some crystals in 
alcohol, let it evaporate spontaneously, and examine. 
See Fig. 13. 

2. Perform the micro- chemical tests in which urea 
nitrate crystals are found, making a drawing of the 
crystals obtained as above. See Fig. 11±. 

3. Add a strong solution of oxalic acid to a solution 
of urea, warm slowly, gently and cautiously a few 
drops of the mixture on the slide, and compare the 
crystals obtained with those of oxalic acid and of urea 
respectively. See Fig. 15. 

REQUIREMENTS. 

Microscope with half-inch and one-fifth-inch objectives. 
(Bausch & Lomb's BB stand is recommended.) Glass slides, cov- 
er-glasses, pipettes, alcohol lamp, nitric acid, oxalic acid, alcohol. 



PHYSIOLOGY OF UREA. 71 



CHAPTEK IX. 



UREA: PHYSIOLOGY, PATHOLOGY, AND CLINICAL 
SIGNIFICANCE. 

A. PHYSIOLOGY. 

Regularity of excretion — Urea is the chief vehi- 
cle by which the nitrogenous food leaves the body. 
About ninety per cent, of the nitrogen taken in the 
food is excreted as urea. Contrary to the statements 
of various authors I find the total amount of urea 
passed in a day not exceedingly variable. In the 
urine of a person of regular habits the daily excretion 
of urea is sometimes remarkably regular : one patient, 
for example, whose urine I examined once a week for 
seven weeks voided a total of 13, 12, 14^, 13£, 13, 
12, 13-J- grammes respectively. Moreover, the amount 
of urea voided by the same person may not vary 
greatly in a term of years. Thus in a case in which I 
examined the urine eight times in five years the urea 
ranged from 14 to 24 grammes, five of the analyses 
showing quantities from 20 to 24 grammes inclusive. 

It would seem that the quantity of urea passed by 
an individual fluctuates within a not very great range, 
and that, if the average for any ten days be compared 
with that of any other ten days, the difference is not 
great. 

In one case the average excretion for a period of ten 
days was to a grain (0.6 gra.) the same as that for 
another period of the same length. 

Quantity per twenty-four hours. — The figures 
given by English observers as the average in twenty- 
four hours, 26 to 33 grammes (412 to 515 grains), I 
regard as being too high. Out of 200 Americans 
whose urine contained neither albumin nor sugar I 
found only 11 to contain as much as 30 gm. 



72 URINARY ANALYSIS. 

(465 grains) in twenty-four hours. Two-thirds 
voided less than 20 gm. (310 grains) in twenty- 
four hours. But inasmuch as nearly all these 
persons were not typically healthy, and in 
fact many were ill enough to consult a physician, I 
can not take their average as the normal one. But 
the urine of such healthy Americans as I have exam- 
ined has scarcely ever contained as much as 500 grains 
of urea. I would assume the quantity to be about 
2 6 -J- gm. (410 grains) in men, and 20-J- gm., or 315 
grains, in women. These are the figures of the French 
observers, Yvon-Berlioz, and I regard them as approach- 
ing more closely our American average than the Eng- 
lish figures do. 

The excretion of urea per hour is said to be 0.015 to 
0.035 gramme for every kilogram of weight; that is, 
0.231 to 0.54 of a grain for every 2J pounds. For 
adults I would regard the smaller figure rather than 
the larger as correct. 

Children are said to void 0.131 gm. a day for every 
kilogram of weight when weighing from 18 to 36 kilo- 
grammes (4-J- grains for every pound when weighing 
from 40 to 80 pounds), and 0.122 gm. when weighing 
from 28 to 5Q kilograms (4 grains per pound from 60 
to 120 pounds.) At this rate we would expect a child 
weighing 40 pounds to pass 180 grains of urea in 
twenty -four hours. 

1 have examined the urine of a number of children. 
The urea figures are given at the end of this chapter. 
Men pass 17 to 21 grammes per liter (8 to 10 grains 
per ounce), and women 16 to 19 (7-J to 9). 

Formation in the body. — Part of the urea excreted 
may possibly be formed in the liver from ammonium 
carbonate. The reasoning that points to the liver as 
the chief seat of urea formation is as follows : 

1. In diabetes, where we know the metabolism of 
hepatic cells is greatly increased, urea is increased 

2. In degenerative changes in the liver, urea forma- 
tion is decreased. 

Unfortunately, however, the first of these premises 
is vulnerable. Out of 45 typical diabetics, in whose 



PHYSIOLOGY OF UREA. 73 

twenty-four hours' urine the author determined the 
urea, half voided from 20 to 40 grammes, (310 to 620 
grains) which is not an excessive amount considering 
the polyuria, and 15 patients voided less than 465 
grains (30 grammes), which is less than the normal 
average of the English. A comparatively low ex- 
cretion of urea is possible even in severe cases of 
diabetes ; for example, one of the writer's patients 
passed only 265 grains of urea in the twenty-four 
hours' urine, containing five-and-a-half per cent, of 
sugar, or nearly 1,250 grains. 

Moreover, in diseases not attended by degenerative 
changes in the liver a low excretion of urea may be 
found : as, for example, in the case referred to the 
writer by Dr. Thomas E. Eoberts, in which in 825 c.c. 
(27 fl. oz.) of urine there was less than 1 gm. (15 
grains) of urea. Women often void as little as 6 
grammes (93 grains) in a day and recover. 

In view of such facts I am inclined to agree with 
Dr. Long, who says, "how or where the conversion 
of nitrogen into urea takes place is not known." 

Effect of diet and exercise Urea is increased by 

animal diet, and mental and physical activity ; decreased 
by non-nitrogenous diet and quietude. Hence, more 
urea is voided during the day than during the night. 
In thirty-one instances in which the writer has examined 
the day urine and night urine of twenty- three patients 
separately the day urea was found to be greater than 
the night urea in twenty-nine out of the thirty-one 
samples examined. In only six of the twenty-nine 
was the day urea as much as twice the night urea, and 
in but two instances, three times. The amount by 
which the day urea exceeded the night varied from 0.3 
gm. (5 grains) to 1 5 gm. (225 grains) ; the average excess 
of day over night was about 2.5 grammes (40 grains). 
One of the two cases in which the night urea exceeded 
the day was that of acute chorea following diphtheria ; 
in the other the diagnosis is unknown. 

Effect of milk diet. — Milk is said to increase urea 
in urine. One of my patients voided 46 gm. (715 
grains) of urea on strict milk diet, but, unfortunately, 



74 URINARY ANALYSIS. 

what his excretion was prior to the diet is not known. 
In another case no increase at all was noticed in a con- 
siderable period of time. Both were cases of slight 
albuminuria without casts. 

B. PATHOLOGY. 

Relative urea and absolute urea Much confu- 
sion has been caused in the past by not distinguishing 
a relative increase in urea from an absolute increase. 
By relative increase in urea we mean an increase in 
urea as compared with some other constituent of the 
urine, notably water. In this book when speaking of 
relative increase of urea I shall mean an increase com- 
pared with the water of the urine, i. e., an increase of 
urea in grains per ounce (grammes per liter). 

Thus, if the urine of a certain patient contain 15 
grains of urea to the ounce of water, urea in this case 
is relatively increased, since 8 to 10 grains per ounce 
is normal. 

By absolute increase in urea we mean increase in the 
total urea for twenty-four hours as compared with the 
normal average quantity for that period : thus, a 
patient who passes 750 grains of urea in twenty-four 
hours, voids urea which is absolutely increased in 
quantity. 

Relative increase and absolute deficiency Some- 
thing which puzzles beginners is the fact that a patient 
may pass urine in which urea is relatively increased 
but absolutely deficient. Thus, suppose a patient 
voids 10 ounces of urine in twenty-four hours contain- 
ing 15 grains of urea to the ounce. Urea is increased 
relatively, since 15 grains to the ounce is one-and-a- 
half times the normal average of 10 grains to the 
ounce ; but urea is decreased absolutely ^ since the total 
product is 10 times 15, or 150 grains total, about one- 
third the normal quantity for twenty-four hours. 

Relative deficiency and absolute increase. — Again, 
in the same urine urea may be relatively deficient and 
absolutely increased : thus, if a patient voids 1 00 
ounces of urine containing 6 grains to the ounce, urea 
is deficient relatively, since 6 grains per ounce is less 



PATHOLOGY OF UREA. 75 

than 6 to 10, the normal range. On the other hand 
urea is increased absolutely, since 600 grains the total 
quantity, is in excess of the normal range, 400 to 500 
grains at most. 

DISEASES IN WHICH UREA IS DECREASED IN GRAINS PER 



OUNCE (RELATIVE DEFICIENCY OF UREA). 

Urea is decreased relatively from physiological causes, 
after copious ingestion of fluids. Pathologically rel- 
ative decrease takes place in the following diseases : 

1. Chronic nephritis, except when dropsy is exces- 
sive. 

2. Diabetes insipidus. 

3. Hysteria (after paroxysm). 

4. Anaemia. 

5. Some cases of neurasthenia. 

EXAMPLES. 

In eighteen cases of chronic nephritis in which the 
twenty-four hours' urine contained large percentage of 
albumin, urea was relatively deficient in all but four. 
In one case but 2 gm. per liter of urea (1 grain per 
ounce) was found. Nine grammes per liter (4 grains 
per ounce) is quite commonly observed in chronic 
interstitial nephritis. In one case of hysteria with 
ancemia urea was as low as 1 gramme per liter (one- 
half grain to the ounce.) The patient recovered and 
afterwards voided normal urine. In some cases of 
neurasthenia the writer has noticed urea 9 to 13 
grammes per liter (4£ to 6 grains per ounce), but 
this is not invariable. 

DISEASES IN WHICH UREA IS INCREASED IN GRAINS PER 



OUNCE (RELATIVE INCREASE). 

Urea is relatively increased physiologically by 
abstinence from liquids or other causes which diminish 
the volume of urine. Pathologically it is increased 
relatively in the following diseases : 

1. Febrile disorders, especially acute rheumatism. 

2. Acute or chronic nephritis, where the urine is 
concentrated and high-colored from dropsy. 



76 URINARY ANALYSIS. 

3. Congestion of the kidneys. 

4. Certain hepatic disorders. 

5. Some cases of diabetes mellitus. 

6. Certain nervous diseases. 

7. Before the convulsions of pregnancy. 

EXAMPLES FROM THE AUTHOR'S CASES. 

In all these cases the twenty-four hoars' urine is understood as 
specified. 

Chronic Nephritis.— In the case of a dropsical woman 31 gm. 
gra. per liter (15 grains per ounce) and subsequently 25 gm. and. 21 
(12 grains and 10 grains). In the case of a woman who passed 
but 40 c.o. (1 fl. oz.) of urine in twenty-four hours, urea was 49 gm. 
per liter (23 grains per ounce). 

Gall-Stone Colic. — In one case 41 gm per liter, 20 grains per 
ounce. 

Diabetes Mellitus. — -The greatest quantity of urea 
ever found by the writer in diabetes was 35 grammes 
per liter (16 grains per ounce). The lowest, 5 gm. per 
liter (2 -J- grains per ounce). In the majority of cases 
10 to 21 gm. per liter (5 to 10 grains per ounce). 
Nervous Diseases : 

Epilepsy, in a boy of twelve years. 

Chronic meningitis. 

Oxaluria. 

Cancer. — In one case of cancer of the intestines 
the writer noticed relative increase of urea in the 
urine. Absolutely it was diminished. 

Convulsions of Pregnancy. — In two cases of 
puerperal nephritis the writer has observed a high per- 
centage of urea, 12 and 16 grains per ounce (25 and 
33 gm. per liter), respectively. In one case the 
patient died of convulsions in less than a day ; in the 
other there was vomiting, diarrhoea, and urine loaded 
with albumin. 

The second case was that of a woman who had a 
history of puerperal convulsions at the same date in a 
previous pregnancy. Her urine was carefully and 
fully examined by me from time to time during the 
early months of pregnancy and found to be abundant, 
pale, of poor quality, urea about 4 grains per ounce 
(9 gm. per liter), albumin small, two per cent. bulk. 
Suddenly, without warning, the urine became scanty, 
concentrated, highly acid, urea increased to 16 grains 



PATHOLOGY OF UREA. 77 

per ounce, and albumin to the enormous figure of 50 
per cent, bulk, or about one per cent, weight. At the 
same time she was seized with violent vomiting and 
purging. 

It is evident that in these cases urea is not decreased 
relatively, as in the urasmia of interstitial nephritis, 
but is decidedly increased. 

CHEMICAL EXERCISE IV. 

Kepeat the determination of urea, this time compar- 
ing the Bartley clinical instrument with the Doremus 
in various ways. 



78 URINARY ANALYSIS. 



CHAPTER X. 



PATHOLOGY AND CLINICAL SIGNIFICANCE OF UREA, 
(CONTINUED.) 

Diseases in which urea is decreased in total 
quantity for the twenty-four hours. 

Urea is decreased in total quantity per twenty-four 
hours (absolute decrease) in the following : 

1. Chronic Diseases. Especially many nervous 
ones; in chlorosis, paralysis, ovarian tumor, uterine 
cancer, chronic nephritis', 

2. In diseases of the liver, notably acute yellow 
atrophy ; 

3. Preceding and during urcemic attacks. 

4. Before paroxysms of gout and asthma. 

5. In yellow-fever and in cholera. 

EXAMPLES FROM THE AUTHOR'S CASES. 

Internal Cancer. — In two cases the urea was absolutely dimin- 
ished. In one of these two relatively and absolutely diminished. 
Eleven grammes (170 grains) total in each case. The diagnosis 
was verified. 

Uterine Fibroid. — In two cases 15 and 14 gm. (225 and 210 
grains) total. 

Chronic Cystitis in an Anaemic Woman.— Eight analyses gave 
an average of only 8.5 gm. (130 grains). The patient had an 
ursemic attack, but recovered and is alive today. 

Chronic N". phritis. — In one case a dropsical woman averaged 
10.5 gm. (165 grains) in nine analyses made during the last month 
of life. 

In twenty-eight fatal cases of chronic nephritis in which dur- 
ing life albumin together with granular, fatty or waxy casts 
were found the average total urea excretion was 14 gm. (210 
grains). When albumin was very abundant urea was below the 
normal in fourteen out of 18 cases, and never above normal. 

In one case a female patient several days before death voided 
only 1.5 gm. (22 grains of urea) in twenty- four hours. 

Occasionally urea is not greatly diminished until shortly before 
death. One patient, male, aged 55, dropsical from head, to foot, 
passing urine loaded with albumin, several weeks before death, 
voided 20 gm. of urea (300 grains). A few days before death 
urea decreased materially. 

Acute Chorea. — In one case, a child, urea was relatively and 



CLINICAL SIGNIFICANCE OF UREA. 79 

absolutely decreased, 10.5 gm. (160 grains) total, and night urea 
exceeded day. 

Chronic Rheumatism. — Patient, male, unable to move, 
averaged 13 grammes (200 grains) in seven analyses covering a 
period of seven weeks, and lived several years afterward. 

Chronic Albuminuria. — A man, aged 45, averaged 21 grammes 
(325 grains) during scattered analyses extending over a period of 
five years. There was absence of other symptoms. 

Chronic Prostatitis. — A man. aged 70, averaged 19 grammes 
(300 grains) in ten analyses made one each week for ten consecu 
tive weeks. He was invariably worse whenever urea fell below 
20 grammes daily; better when it was higher. 

Psoas Abscess. — A child of 12 years; urea 7 grammes (110 
grains). The case resulted fatally. 

Nervous Diseases.— In the case of one hundred patients with 
various nervous diseases the urea per twenty-four hours in the 
majority of cases was from 14 to 30 grammes (210 to 465 grains). 
In about one-quarter of the cases it was less than 14 grammes, 
but in only about 5 per cent, of the cases above 30 grammes. 
The diseases in which urea was greatly decreased, below 14 gm. 
(210 grains), were as follows: 

Great relative and absolute decrease.— Epilepsy, neurasthenia; 
reflex nervous headaches from uterine diseases; acute chorea fol- 
lowing diphtheria; locomotor-ataxia. 

Great absolute decrease only — Irregular cerebral development; 
spinal irritation, with chronic meningitis; epilepsy; cerebral 
hemorrhage and hemiplegia; aphasia, with paralysis. In the last 
two cases, 11.5 gm. (178 grains) and 7 gm. (110 grains) respectively. 

Moderate decrease. — Diseases in which the deficiency of 
urea was moderate, 14 to 17 grammes (220 to 265 grains) in 
twenty-four hours were as follows: writer's cramp; oxaluria with 
mental and nervous symptoms; epilepsy in a young girl; hysteria 
in a neurotic woman; neuritis; cerebral tumor: insanity (reflex 
from uterine disease); posterior spinal sclerosis; paralysis agitans: 
paralysis from softening of the brain; nervous symptoms reflex 
from uterine disease (two cases); neurasthenia; neurasthenia with 
tremor. 

urea nearly normal. — Diseases in which the excretion of 
urea was nearly normal, 18 to 25 gm. (280 to 390 grains), were the 
following: Chronic cerebral meningitis and facial paralysis; brain 
symptoms following sun-stroke; neurasthenia (three cases); epi- 
lepsy in a child of 11; nervous symptoms reflex from uterine dis- 
order; epilepsy in a boy of 12; localized chorea; melancholia fol- 
lowed by suicide; congenital neurasthenia; cephalalgia following 
pneumonia; sexual neurasthenia; hypochondria; nervous symp- 
toms reflex from disease of the eye; hysteria in several male 
patients; chorea; reflex epilepsy; epilepsy; melancholia. 

Urea normal. — Diseases in which urea was full normal were 
the following: Nervous symptoms, from worry and abuse of 
tobacco; epileptoid convulsions; melancholia; nervous symptoms 
reflex from uterine disease, and from rectal diseases; torticollis 
in a neuropath; epilepsy in a boy. 



80 URINARY ANALYSIS. 

DISEASES IN WHICH UREA IS INCREASED IN TOTAL QUAN- 
TITY FOR TWENTY-FOUR HOURS (ABSOLUTE INCREASE). 

Urea is increased in absolute quantity (total per 
twenty- four hours) in — - 

1. Acute febrile diseases with emaciation, as typhoid 
fever; pneumonia; the exanthematous diseases; ty- 
phus ; to some extent in remittent fevers ; inter mitten ts 
before the chill ; 

2. Pyaemia; 

3. Some cases of diabetes; 

<±. Atrophy from dyspepsia in children (Parrot- 
Kobin) ; 

5. Phosphorus poisoning; 

6. Some nervous diseases, as progressive muscular 
atrophy ; 

7. Sometimes in diffuse bronchial catarrh without 
fever. 

EXAMPLES FROM AUTHOR'S CASES. 

Pneumonia. — In one case the patient, male, on the second day 
and before the diagnosis was established with certainty passed 4^U 
gm. (750 grains). Convalescing passed but 30 gm. (465 grains ) 

Diabetes. — In one case a male patient passed 81 grammes (125) 
grains). Six out of 42 patients voided more than 50 gm. (775 
grains). 

C. CLINICAL NOTES. 

1. A high figure of relative urea (grammes per 
liter, grains per ounce) is not necessarily a favorable 
sign in acute or chronic nephritis, for it may mean 
merely scanty urine, which is usually an unfavorable 
sign. 

2. A low figure of urea, relative and absolute, is 
almost always observed in chronic nephritis. 

3. Patients with chronic nephritis seldom show 
increase in absolute urea (grammes per twenty-four 
hours, grains per twenty-four hours) proportionately 
to increase in urine voided. 

4. In one case under the influence of diuretin the 
amount of absolute urea was diminished one-half, 
although the quantity of urine was increased six- fold. 

5. A patient on the same diet may pass more urea 



CLINICAL SIGNIFICANCE OF UREA. 81 

both absolutely and relatively in 1,000 c.c. of urine 
(33 fl. oz.) than in 2,000 (66 fl. oz.) 

6. In diabetes the safest excretion of absolute urea 
appears to be from 20 to 30 grammes (310 to 465 
grains) in twenty-four hours. The mortality in cases 
where more than 60 grammes (930 grains) are voided 
is high. 

7. It is possible for a pregnant woman with a his- 
tory of convulsions in a previous pregnancy to be con- 
fined without convulsions when 20 days before confine- 
ment urea is but 8 gm. per liter (4 grains per oz.) and 
7 gm. per twenty-four hours (125 grains), albumin 
and casts being absent. 

8. It is possible for a pregnant woman with the 
urine and urea of chronic nephritis to be delivered 
safely and to have no convulsions after delivery. 

9. On the other hand, it is possible for a pregnant 
woman to die of uraemic convulsions when twenty-four 
hours before death urea was 25 gm. per liter (12 grains 
per ounce), albumin and casts, granular and waxy, 
being present. 

10. It is possible for a pregnant woman to die of 
convulsions when a week before death urea is normal 
both relatively and absolutely, albumin being a plain 
trace, but no casts present. 

11. It is possible for a pregnant woman to have 
numerous convulsions at term and survive, who passed 
20 gm. (310 grains) of urea in twenty-four hours a 
few days before confinement, albumin being between 
first and second mark on Esbach tube, casts, a few hy- 
aline. 

12. Drugs which are said to diminish urea are al- 
cohol, digitalis, mercury, tea, valerian, lead, all drugs 
which interfere with the functions of the liver ; phospho- 
rus to increase urea temporarily ; quinine to diminish 
urea at first ; potassium bromide to decrease urea while 
the bromide is being eliminated ; arsenic to increase 
it at first. 



82 URINARY ANALYSIS. 

The author has noticed a diminution of urea in cer- 
tain cases in which diuretin was given, but cannot sav 
positively that it is a characteristic of this drug. 

13. The drugs which are said to increase urea are 
the mineral acids, excess of alkaline chlorides, iron 
u tonics," squill, juniper, potassium chlorate, pepsin, 
maltin, euonymin, mercuric chloride, salicylic acid, 
benzoic acid, lithium benzoate, colchicum, and drugs 
which stimulate the liver. 

The author has verified repeatedly this statement in 
regard to lithium benzoate, which will often in- 
crease both urine and urea per twenty-four hours, and 
sometimes increase relative urea. 

14. In certain cases where there are obscure ner- 
vous symptoms, reasoning by exclusion leads us to 
suppose that retention of urea in the body is the cause 
of the trouble. Fifteen analyses made by the author 
in the case of a chronic invalid, from the year 1S91 
to death in 1896, showed usually about 10 gm. (155 
grains) or less of urea, never more than 13 gm. (200 
grains), and once or twice less than 7 gm. (105 
grains). To such cases Dr. Delamater has given the 
name urcemia chronica. Less than 13 grammes 
(200 grains) of urea occurred in other cases quite 
frequently. 

15. Of interest in confirming the writer's observations 
is the following : Lucas-Championniere has found in 
800 determinations that the quantity of urea on the 
average does not, as is generally believed, vary 
between 375 and 4.50 grains, but reallv between 225 
and 300 grains. Diminution of urea is most marked 
in ovarian cancer where, before surgical interference, 
effort should be made to increase the amount of urea 
by rest, milk diet, and relief of pain (anodynes). In 
mild ovarian disease urea may fall below 100 grains in 
twenty-four hours, to rise rapidly above it on milk diet. 
Pain reduces excretion of urea, and the patient's vital- 
ity may be thus so lowered as to influence materially 
the success of operation. Success of operation is in- 
versely proportional to the quantity of urea before the 
operation. The second or third day after major 



CLINICAL SIGNIFICANCE OF UREA. 83 

operations the proportion of urea increases; thus, 
after removal of the appendages of both sides urea may 
rise from 60 or 75 grains to 375 grains. 

UREA IN THE URINE OF CHILDREN. 

GlRLS. — Six analyses of the twenty-four hours' urine of a girl 
jive years of age, showed an average of 12 to 13 gtn. per liter (6 
grains per ounce), and an average total of 8 grammes (132 
grains). Albumin in small quantity was constantly present, but 
no casts. 

In a girl of six years, urea was 8£ gm. per liter (4 grains per 
ounce); total 11 gm. (170 grains). 

A girl of eight years voided 12 gm. per liter (5£ grains per 
ounce); total 10£ grammes or 160 grains. 

A girl of ten years voided 21 gm. per liter (10 grains per ounce); 
total 14| grammes (230 grains). 

A girl of twelve years voided 21 gm. per liter (10 grains per 
ounce) and 19 gm. total (300 grains). 

Two other girls, ages unknown, voided 10 gm. (155 grains) and 
11 grammes (175 grains), respectively in twenty-four hours. 

From these cases it appears that female children between 5 and 
15 years old void from 8 to 19 grammes, 130 to 300 grains. 

Boys.— A boy of twelve years, weight 82 pounds, voided on an 
average 18 gm. per liter, 8 grains per ounce; total 11 gm., 175 
grains. 

A boy of twelve years, weighing 84 pounds, voided 17 gm. per 
liter, 8 grains per ounce; 13 gm. total or 200 grains. 

A feeble-minded boy of ten years voided 19 gm. per liter (9 
grains per ounce); total 8 grammes, 125 grains. 

A boy of twelve years, with subacute diffuse nephritis, voided 
200 grains total of urea on ten separate occasions (13 grammes 
per twenty-four hours). 

An infant barely one year old, male, slowly dying of an obscure 
disorder in which the urine contained albumin and at times traces 
of blood, but no casts, voided but 2gm. urea per liter (1 grain per 
ounce), and never over 2 grammes total or 30 grains during six 
weeks of fatal illness. 

A diabetic boy of ten years, averaged 18 gm. per liter (8 1-2 
grains per ounce); total averaged 24 grammes, about 400 grains. 
Case terminated fatally in a few years. 

A diabetic girl of twelve years, passed 23 gm. per liter (11 grains 
per ounce) and 4o grammes total or 665 grains. This case soon 
terminated fatally. 

Epileptic Children. — A girl of eight years (epileptoid) voided 
24^ gm. per liter (11 grains per ounce); total 13| gm. (210 grains). 

A boy of ten years voided 26 gm. per liter. 12^ grains per 
ounce; total 19 gm. or 195 grains. 

A boy of eleven years voided 12 gm. per liter, 5£ grains per 
ounce; total 18£ gm. (285 grains). 

Another epileptic boy, C. T , age unknown, voided on an 
average 32 gm. per liter, 16 grains per ounce; total averaged 27 
gm or 425 grains. 

In other words, there seems to be a tendency in the majority of 
epileptic cases in children toward relative increase in the excre- 
tion of urea, and in some cases absolute as well. 



84 URINARY ANALYSIS. 

CHEMICAL EXERCISE IV. 

Compare the three clinical instruments, Bartley, 

Doremus, and Squibb, using — (a) a known solution of 

urea, and (b) the same sample of urine. 

For the Liebig process for urea and the Kjeldahl method of 
determining total nitrogen, see Appendix. 



CHEMISTRY OF URIC ACID. 85 



CHAPTEE XI. 



THE CHEMISTRY OF URIC ACID. 

TTrio acid occurs uncorabined in normal urine in but 
minute quantity. Combined it forms salts called urates, 
which occur in solution in the urine in considerable 
quantity. It is the custom among physicians, how- 
ever, to use the term "uric acid" rather than urates, 
in referring to various clinical conditions in which these 
substances are thought to play a part. It must be dis- 
tinctly understood that the urates may be found both 
dissolved in the urine, and undissolved in the sediment 
of urine. The following table will make the matter 
clear : 

URIC ACID AND URATES. 

Uric acid. — In solution, normally, in small quantity. In the 
sediment, abnormally in comparative abundance. 

Urates. — Normally in solution in comparative abundance. Ab- 
normally in sediment in comparative abundance. 

The most convenient method to determine the 
quantity of urates in urine is to convert them into uric 
acid ; or, more scientifically stated, to set free the uric 
acid which they contain, and determine the quantity 
of that. Hence the chemist speaks of the amount of 
uric acid the urine contains, rather than the amount 
of urates. It should be understood also, before pro- 
ceeding further, that uric acid is a weak acid, and 
but loosely combined with the various bases, so that on 
addition of stronger acids, as hydrochloric, to urates, 
the stronger acid drives away the uric acid from its 
combination, or "sets it free," as chemists say. More- 
over, uric acid differs from the familiar mineral acids, 
nitric, sulphuric, and the like, in being a crystalline 
solids instead of a liquid, and in being difficultly soluble 
in water. 

Normal urine, then, contains in solution uric acid 
combined with sodium, potassium, etc. , forming urates 



86 URINARY ANALYSIS. 

of sodium, potassium, etc. Under abnormal 
circumstances, to be described later, these urates 
may be thrown out of solution and appear as a sedi- 
ment; and, still further, uric acid, itself, may be set 
free, and appear, itself, in the sediment. All normal 
urine contains urates dissolved in it. Some abnormal 
urine may contain urates as a sediment, some abnor- 
mal urine may contain uric acid as a sediment, some 
abnormal urine may contain both urates and uric acid 
as a sediment. In the author's experience as a 
teacher much confusion results in the minds of students 
unless these facts just stated are thoroughly under- 
stood. 

URIC ACID (FORMING URATES) IN SOLUTION. 

Synonyms: 

Uric acid. German, Harnsailre, French, Acide 
Urique. 

Urates. German, Harnsailre Sateen, Uraten; 
French, les urates. 

Chemical constitution. — Uric acid: — C 6 H 4 N 4 0, 
an organic substance containing 33 per cent, of 
nitrogen; a dibasic acid, H 2 (C 5 IJ 2 N 4 3 ), that is con- 
tains two atoms of hydrogen replaceable by two of 
a monad metal. 

NH.C.NH^ pn , ^ 

The structural formula is saidto be CO<; CXH^ ' 

NH.CO 

a derivate of acrylic acid or acrylic acid diureid. The diureids are 
compounds formed from two molecules of urea. Acrylic acid is 
C,H 4 2 . 

Urates. — Compounds of uric acid in which one or 
two atoms of hydrogen of the acid have been replaced 
by an equivalent of a metal, thus, sodium urate, 
Na 2 (C 6 H 2 N 4 O s ). Two kinds of urates are recognized, 
namely, acid urates and neutral urates. Acid urates 
(biurates) are those in which but one atom of hydro- 
gen has been replaced by the metal, as Na(C B H s N 4 3 ), 
acid sodium urate. Neutral (normal) urates are those 
in which both replaceable hydrogen atoms have been 
set free, as in the case of sodium urate above. 
The formation of the two different kinds of urates is shown by 



CHEMISTRY OF URIC ACID. 87 

the following equations, according as uric acid combines with 
potassium, sodium, or ammonium carbonate or hydrate: 

C6H 4 N 4 03+2NaOH— Na a (C 6 H 8 N 4 0sH2H 2 0. 

C 5 H 4 N 4 03+Na 2 C03=NaH(C 6 H 2 N 4 03)+NaHC03. 

The following table shows the different urates, let- 
ting TJ represent the unchangeable bracket C 6 H 2 N 4 

8 : 

Urates.* Formula. Solubility in water. 

Acid ammonium NH 4 HU" 1 in 1600 

Acid sodium Nali£7 1 in 1200 

Acid potassium KHL 7 1 in 800 

Acid calcium CaH a C7" t 1 in 600 

Neutral sodium Na 2 U" 1 in 77 

Neutral potassium K a U 1 in 44 

Neutral calcium CaL 7 1 in 1500 

Occurrence. Uric acid: — In solution in all normal 
urine of human beings in the form of urates. In the 
sediment under abnormal conditions as free uric acid 
or as urates. More abundantly in the urine of birds 
and scaly amphibians; in large quantities in "chalk- 
stones," calculi, and in guano. 

Form. Uric acid in sediments is crystalline. Urates 
in sediments may be either crystalline or amorphous. 
(See Sediments.) 

Solubility: 
A. Uric Acid : 

1. Soluble with difficulty in water: 1 in 15000 cold 

water; 1 in 1900 boiling water. 

2. Insoluble in alcohol and ether; soluble in boiling 

glycerine. 
3.. Soluble in sulphuric acid without decomposition. 

4. Soluble in nitric acid with decomposition. 

5. Soluble in solutions of caustic alkalies, as caustic 

soda and caustic potash, less so in ammonia, 

6. Soluble in alkaline solutions of the lactates, 

phosphates, as sodium phosphate; carbonates, 
as lithium carbonate; acetates and borates, 
forming neutral salts. According to Haig 
salicylate of sodium is a powerful solvent. 



* According to Bence Jones the salts of uric acid are really 
quadrurates, composed of a molecule of acid urate and a molecule 
uric acid, thus potassium quadrurate C5H3KN4O3.' bH 4 N0 8 or K 
HC7H a C7. The water of the urine breaks these up into tree uric 
acid and acid urates. 



88 UKINARY ANALYSIS. 

7. In solutions of piperazine, lycetol, lysidin, tartar- 

lithine, tetra ethyl-ammonium hydroxide.* 

8. According to Klemperer, solutions of pure urea 

exercise solvent action on uric acid ; according 
to Rudel, a liter of a 2 per cent, solution 
of urea dissolves 0.529 gm. of uric acid. 

9. In the body, sodium chloride by forming sodium 

carbonate, contributes to the solubility of uric 
acid in the blood. 

10. According to Posner urine best dissolves uric 
acid when of low specific gravity, and not in- 
tense reaction of either kind. 

B. Neutral Urates : 

1. Lithium urate most soluble in water; potassium 

and sodium next, calcium least. 

2. Readily soluble in hot water. 

(See Sediments for individual solubilities.) 

C. Acid Urates : 

1. Sparingly soluble in cold water, especially am- 

monium urate. 

2. Eeadily soluble in hot water. 

(See Sediments for individual solubilities.) 

Note: — Hence most urinary sediments of urates are acid urates. 
Owing to the feeble solubility of the acid urates in cold water, these 
substances are deposited as the urine cools. On the other hand 
urine highly charged with neutral urates may remain clear but, 
on addition of a strong mineral acid, as nitric acid, a whitish 
opacity is occasioned owing to formation and separation of acid 
urates, which, however, may be dissolved by heat. 

State : Pure uric acid is a white, odorless, tasteless 

powder consisting of very small rhombic prisms or 

plates. As obtained from urine it is colored pinkish 

by urinary pigments. 

Preparation: 

A. Synthetically in several ways: 

1. By fusing urea and glycocoll (amido-acetic acid) the latter 
in one-tenth the weight of the former (hydantoin and biuret are 
intermediate products), thus: 

C 2 H 5 N0 2 +3CH4N 2 0=C6H 4 N 4 O s +3NH 8 +H 2 0. 
Glycocoll, Urea, Uric acid. 

2. By heating trichlor-lactic acid-amide (cyanuric acid, carbon- 
dioxide, and other by-products not considered) with excess of 
urea: C,Cl 8 H40 2 N+2CH4N a O=CBH4N 4 08+H 2 0+NH4Cl+2HCl. 

*See author's Chemistry, 4th ed. , p. 338. 



CHEMISTRY OF URIC ACID. 89 

3. From isobarbituric acid, a ureide of oxypyruvic acid. 
B. From the excrement of serpents, guano, or urine as follows: 

1. From serpent excrement by boiling with dilute solution of 
caustic potash and filtering hot; the hot nitrate contains the neu- 
tral potassium urate. On passing carbonic acid gas into it one- 
half the potassium is displaced, and the acid potassium urate pre- 
cipitated according to the equation— 

2C6H 2 K 2 N 4 3 +C0 2 +H 2 0=K 2 C0 3 +2C 6 H S KN 4 3 
Neutral poassium urate Acid potassium urate 

The acid urate being washed is decomposed by hydrochloric acid 
and yields uric acid. 

2. From guano by boiling with a solution of one part borax in 
20 parts water; acidulate the solution and a brown, impure pre- 
cipitate of uric acid is obtained, which, being washed and decom- 
posed with hydrochloric acid, yields a purer uric acid. 

3. From urine by adding to it one-fifth its volume of hydrochlo- 
ric acid to decompose the urates, allowing to stand in a cool 
place for several days, decanting, and dissolving the separated 
crystals (adhering to the sides of the vessel) in sulphuric acid, and 
precipitating with water. 

Relationships. 1. Uric acid strongly heated decomposes with 
formation of urea, hydrocyanic acid, cyanuric acid, and am- 
monia. 

2. Heated with concentrated hydrochloric acid in sealed tubes 
to 170° C, uric acid splits into glycocoll, carbon dioxide, and am- 
monia. 

3. Oxidizing agents cause splitting, and oxidation takes place, 
either a mono-ureid or di-ureid being formed. Oxidation of uric 
acid with lead perocde produces carhm dioxide, oxalic acid, urea, 
and allantoin (glyoxyl diureid). Oxidation with nitric acid, in the 
cold, produces urea and alloxan, (raesoxalyl urea, a monoureid). 
Warming uric acid with nitric acid produces alloxan, carbon 
dioxide, parabanic acid (oxalyl urea, C 8 H ? N 2 O<0. Parabanic acid 
on addition of water passes into oxaluric acid C 3 H 4 No0 4 , traces 
of which occur in the urine, and which easily splits into oxalic 
acid and urea. 

4 Reduction of uric acid with sodium amalgam produces 
xanthin and then hypoxanthin (sarcin). 

5. Uric acid may be made synthetically from isobarbituric acid, 
a ureide of oxypyruvic acid or of alpha-beta dioxyacrylic acid, 
which when oxidized is transformed into an isomer of dial uric 
acid. This last, heated to 100°C. (212° F.). with one molecule of 
urea and seven times its weight of sulphuric acid, produces uric 
acid which in every way resembles ordinary uric acid. 

6 Uric acid is nearly related also to the following other sub- 
stances: Hydantoin. guanin, hippuric acid, inosic (inosinic) acid, 
the bile-acids, theobromine, caffein, and thein. 

Chemical Reactions: 

A. The Mukexide Test : This test is characteristic 
of uric acid and urates, Treat a few crystals of uric 
acid with a few drops of nitric acid, which dissolves the 
former with a strong development of gas (nitrogen 
and carbonic acid), and, after thoroughly drying on the 
water bath (Fig. %6) and cooling, a beautiful red resi- 




90 URINARY ANALYSIS. 

due (urea and alloxan) is obtained 
which turns purple-red (murexide 
or purpurate of ammonia, C 8 H 4 (N 
H 4 )N 5 6 ) on addition of a little am- 
monia; or, after cooling, on addi- Fig. 26. Water bath, 
tion of a little caustic soda solution a bluish-violet, 
the latter disappearing quickly on warming (differen- 
tiation from guanin, -etc.) 

Note. — The test as above described is not so uniformly successful 
as the author's modification of it, as follows: Add one cubic centi- 
meter of nitric acid to ten c.c. of water, mix thoroughly, pour 
into a test-tube, add uric acid crystals to the amount, say of 20 or 
30 milligrams (about half a grain), boil thoroughly over a spirit- 
lamp till the uric acid is all dissolved and effervescence c^ms •-;. 
Evaporate to dryness over the water-bath, let cool, touch with a 
rod which has been dipped into ammonia and a brilliant purple- 
red at once appears, changed to bluish-violet on addition of 
caustic soda solution. If the uric acid solution in dilute nitric 
acid is evaporated on a flat porcelain surface, the student may 
trace his initials on the residue, u^ing a glass rod which has been 
dipped into ammonia. The letters stand out in brilliant purple 
red. as compared with the yellowish residue which has not been 
moistened with the ammonia. 

B. Schiff's test: Dissolve a little uric acid in as 
small a quantity of sodic carbonate solution as possible; 
a piece of filtering paper being moistened with some 
solution of silver nitrate, a drop of the uric acid solu- 
tion in the sodic carbonate, carried on a glass rod, is 
made to touch the paper, when a greyish stain of me- 
tallic silver appears. The stain is black, if the uric 
acid is in amount 0.001 per cent, or more. 

C. Reduction of Cupric Solutions : 

Boil a little Fehling's solution (see Sugar) with a 
solution of uric acid, and a reddish precipitate of 
cuprous oxide forms. An alkaline solution of bismuth 
is not similarly reduced. 
Quantitative determination of uric acid. 

All urates are decomposed by dilute hydrochloric 
acid, with liberation of uric acid, according to the 
equation: Na 2 (G 5 H 2 lSr 4 3 )+2HCl+C 5 H 6 N 4 8 . On this 

sodium urate uric acid 

fact is based a method for determining the quantity of 
uric acid, which is done by adding to a given volume 
urine one- tenth its volume of hydrochloric acid, col- 
lecting the crystals of uric acid which separate, drying 



CHEMISTRY OF URIC ACID. 



91 




Fig. 27. Eva 
Dish. 



■ rating 



and weighing. Full details of this process are given 
in Chemical Exercise Y. (For the Ludwig-Salkowski, 
Hay craft, Hopkins, and other methods, see Appendix.) 

CHEMICAL EXERCISE V. 

1. The student having obtained some urine of specific 
gravity not less than 1020 should measure off 200 c.c.(T 
fl. oz.)intoa porcelain evaporating 
dish(i^>. 07), add 10 c.c. (3 flui- 
drachms) of chemically pure hy- 
drochloric acid, stir with a glass 
rod, and set aside in a cool, dark 
place for 24 to 48 hours. At the 
end of that time crystals will be 
observed adhering to the dish. Decant 
the urine, rub off the crystals, by 
means of a glass rod having a bit of 
rubber tubing on the end, and pour 
the whole into a tapering glass vessel 
of any kind, using wash-bottle {Fig. 
28) if necessary. Let settle, decant 
supernatant fluid, add more water, let 
settle again, and the crystals re- 
maining at the bottom will now 
be in condition for the murexide 
test, which try. 

FlG. 28. Wash- 
bottle. 
Note — The wash-bottle enables the operator to blow a fine 
stream of water with considerable force into the disb. thus re- 
moving crystals which otherwise cannot be poured off with the 
rest. 

2. Procure some urine of specific gravity not less 
than 1025, or concentrate any urine by boiling until 
of that specific gravity, and set aside in a cold (40° F.) 
place. It becomes cloud}^ from deposition of acid 
urates, which are less soluble in cold water than in 
warm. Now remove to a warm room, or set the glass 
in hot water, and the urine becomes clear again, owing 
to the ready solubility of these urates in hot water. 




92 URINARY ANALYSIS. 

MICROSCOPICAL EXERCISE II. 

Into the sediment of uric acid crystals obtained in 
Chemical Exercise III. dip a camel's-hair brush, and 
remove the crystals adhering to it to a glass slide. 
Examine with a power of 150 diameters or upward, 
and note a large number of crystals of various forms, 
but all of yellowish-red color, which latter is character- 
istic. (Study of the forms will be taken up under the 
head of Uric Acid Sediments.) 



PHYSIOLOGY OF URIC ACID. 93 



CHAPTEE XII. 

PHYSIOLOGY OF URIC ACID. 

History. — Scheele discovered uric acid in 1776 and 
thought it solely a constituent of urinary calculi, hence 
named it lithic acid, from the Greek lithos, signifying 
a stone. In 1797 Wollaston showed that gouty concre- 
tions were composed of sodium urate. In 1848 Gar- 
rod claimed that an excess of uric acid existed in the 
blood prior to an attack of true gout and at the period 
of it. In 1884 to 1892 Alexander Haig has found that 
the excretion of uric acid can be made to vary at any 
time and in any direction. In 1892 Sir William Rob- 
erts made the announcement that the amorphous urates 
are quadrurates normally, and that any departure from 
this condition must be regarded as pathological. 
Horbaczewski has shown that uric acid originates from 
nuclein, and Kuehnau that the leucocytes are the princi- 
pal, if not the exclusive source of the formative materials 
of uric acid. 

Difficulties. — Almost insurmountable difficulties lie 
in the way of reconciling the theories of different ob- 
servers as to the formation, source, and quantity of 
uric acid. For example Haig, using Haycraft's pro- 
cess, speaks of large quantities of uric acid in abnormal 
conditions, sometimes producing a ratio of urea to uric 
acid as low as 14 or 12 to 1. Herter, on the other 
hand, asserts that a ratio of urea to uric acid lower 
than 20 to 1 is impossible. The trouble is due to the 
different chemical processes used for determination of 
uric acid, which in the same sample of urine will show 
widely different results. 

The following is a resume of the different theories 
which comprise our knowledge to date. 

Formation in the body. — Since uric acid is regarded 
as a diureid of acrylic acid, i. e. , by oxidation, splits 



94 URINARY ANALYSIS. 

up into two molecules of urea and one of a non -nitro- 
genous acid, it has been assumed that, when the 
process of oxidation is imperfectly performed within 
the body, free uric acid will be found in excess in the 
urine. But although uric acid is indeed a less oxidized 
substance than urea, the latter is probably derived 
from a different source, at least in greater part. 
Minkowski finds, so far as birds go, that ammonia and 
lactic acids have to do with the formation of uric acid, 
and that the liver is the chief seat of formation. 
Geese with their livers extirpated show a very signifi- 
cant decrease in elimination of uric acid, while elimi- 
nation of ammonia is increased, and considerable 
amounts of lactic acid occur in the urine. The rem- 
nant of uric acid in the urine after extirpation of the 
liver originates from xanthin or similar products. 

Ebstein's theory is that uric acid is a by-product 
from insufficient oxidation of the nitrogenous waste 
into urea. Jaksch tends to uphold this theory, hav- 
ing recently concluded that the "uric acid diathesis 1 ' is 
due to disorders of the red blood-corpuscles, the vehi- 
cle by which oxygen is carried. 

Horbaczewski and his pupils think that uric acid 
originates from nuclein, probably through the inter- 
mediary of adenin, which is related to xanthin and 
hypoxanthin. Uric acid is, according to this view, 
formed in the spleen, and is not notably influenced by 
alimentation. 

Kuehnau concludes that the leucocytes are the 
principal, if not the exclusive, source of the forma ive 
materials of uric acid. 

Quantity. — The average amount of uric acid ex- 
creted in twenty -four hours is said to be 0.7 gm. (lOf 
grains), with a possible range of from 0.4 to 0.8 gm. 
(6i to 12£ grains). 

The ratio of urea to uric acid is differently stated. 
Haig calls it 33 to 1 ; Parkes, 45 to 1 ; Meyer, 50 to 1 ; 
Herter, 50 to 1 ; Yvon-Berlioz, 40 to 1 * Hammarsten, 
from 50 to 1 up to 70 to 1. The statement of Haig 
that the formation of uric acid is always in relation to 
the urea formed, and as 1 is to 33, is said to be entirely 



PHYSIOLOGY OF URIC ACID. 95 

disproved by the fact shown recently that the ratio 
varies normally at different periods of the day. 

The author's observations tend to show that assump- 
tion of a fixed urea-uric acid ratio for that of health is 
entirely out of the question. The ratio of urea to uric 
acid fluctuates, but in all probability within more or 
less definite limits in the same individual. E. E. 
Smith has, independently, arrived at the same con- 
clusion and thinks the range to be from 45 to 1 to 60 
to 1. The author is in the habit of regarding any 
ratio below 30 to 1 as certainly indicating very large 
excess of uric acid, and is skeptical about the ratios below 
20 to 1 reported by some observers. With uric acid 
determinations carefully conducted I have never seen 
a ratio below 20 to 1, though by means of the older 
processes, and perhaps one or two of the more modern 
ones, whose value is yet doubtful, ratios below 20 to 
1 have often been found by me. It is said that in 
infants the ratio may be as low as 14 to 1, but in a 
child two years old I recently found the ratio 45 to 1. 

EFFECT ON URIC ACID OF DIET AND REGIMEN. 

The only point, says Roberts, which is really clear 
about diet, is that the excretion of uric acid is height- 
ened by increasing the albuminoid ingredients of the 
food. Sugar, fat, and fruit are not proved to have the 
slightest direct influence on the production and excre- 
tion of uric acid. I hold, on the contrary, that it is 
a clinical fact, which has been verified time and again, 
that abstinence from sweets improves the general con- 
dition of uricaemic patients, at least those subject to 
uric acid- deposits. 

It is said that on an abundant meat diet uric acid 
may amount to 2 gms. (31 grains) in 24 hours. The 
author has, however, eaten heartily of butcher's meat, 
three times daily for the last five years, but has not 
found more than 1 gm. of uric acid at most in his 
urine. Things which increase uric acid according to 
various authors are milk, beef- tea and beef- ex tracts, 
alcoholic drinks, especially champagne, muscular 
fatigue, hot rooms, weather in which there are warm 



06 URINARY ANALYSIS. 

southwest winds. Uric acid is said to be decreased by 
vegetable diet, moderate exercise, such as bicycle rid- 
ing in moderation, copious draughts of water. 

According to Haig the excretion of uric acid is rel- 
atively large during the three or four hours after 
breakfast, i. e., during the period of u alkaline tide." 

Action of drugs — The drugs which are said to 

increase uric acid in the urine are the following : 

Euonymin, Quinine (in small doses), Salicylates. 

Mercuric chloride, Phosphate of sodium, Colchicum, 

Alkalies generally. 

Those which decrease it in the urine are, according to 
Haig: 

Acids, Lead, Acid phosphate of sodium « 

Iron, Manganese Various sulphates, 

Lithia, Calcium chloride, Various chlorides; 

also, 

Opium, Antipyrin, Hyposulphites, 

Cocaine, Caffeine, Strychnine. 

Mercury, The nitrites, 

Haig's View of Uric Acid. Haig's observations are that 
uric acid is not influenced by dietary or medication in its forma- 
tion, that being regarded as constant and uniform with the pro- 
duction of urea in the ratio of 1 to 33. As a substance insoluble 
in acid media, uric acid, when the blood and fluids of the tissues 
decrease in alkalinity, is no longer held in solution by these 
liquids and thus carried through the renal system, but is deposited 
in the organism, largely in the liver and spleen. If, for any 
reason, this decreased alkalinity be overcome, and a wave of in- 
creased alkalinity induced, as by administration of alkalies, these 
deposits are redissolved and carried in the current, producing an 
excess in actual circulation. 

The Lithia Question. — Haig admits that compounds 
of lithium will dissolve uric acid in the test-tube, but 
insists that in the body the lithium salts never have a 
chance to affect uric acid, since lithium forms, accord- 
ing to Eose, a nearly insoluble triple phosphate with 
the phosphate of sodium or with the triple phosphates 
of ammonium and sodium, salts generally present in 
animal fluids. Again sodium phosphate is a good sol- 
vent of uric acid, and the lithium, by uniting with it, 
robs the blood of one of the natural solvents of uric 
acid. Moreover, Haig found, taking lithia himself, 
that uric acid was decreased in his urine, and accounted 
for it as above. 



PHYSIOLOGY OF URIC ACID. 97 

Chemists doubt the value of lithium salts as uric acid 
solvents in the body. Clinical testimony, however, as 
to the diuretic action of certain lithium compounds, 
(benzoate and citrate) is certainly great, and also as to 
the benefit derived from their action on patients sup- 
posedly suffering from uric acid complaints. Dr. Mary 
Putnam Jacobi, in objecting to Haig's theories, speaks 
of a typical lithaemic patient whom mild diet with 
lithia and vichy greatly relieved. Discussion of this 
subject properly belongs to a work on therapeutics and 
will not be continued here. 

Opponents of Haig's Yiews : Many observers fail 
to agree with Haig, some attacking him on one side, 
others on another. Clinically his dietary and regimen 
are of undoubted benefit in some cases, though not in 
others. The profession, however, is under obligations 
to him for his brilliant and earnest research work. 
His position has been strengthened by the observation 
recently made, that in 1,000 consecutive determinations 
of the urea-uric acid ratio in an individual the ratio of 
urea to uric acid was found to be 35 to 1. 



98 URINARY ANALYSIS. 



CHAPTER XIII. 

PATHOLOGY OF URIC ACID. 

In considering the increase of uric acid in the urine, 
the increase in the total quantity for twenty -four 
hours is meant. 

It is probable that a sediment of amorphous urates, 
especially if occurring in urine of specific gravity less 
than 1025, is fairly reliable evidence that uric acid is in 
excess in that urine, but the latter may be in excess 
and yet no sediment betray it, hence quantitative de- 
termination of the whole uric acid in twenty-four 
hours should be made. 

On the other hand, a sediment of uric acid itself 
gives no indication of an excess of the total uric acid, 
signifying merely some change in the saline constit- 
uents, coloring-matters, or acidity, hence again quan- 
titative determination is needed. 

In general it is held that uric acid is increased when- 
ever either an increased formation of leucocytes, rich 
in nuclein, takes place in the blood or an increased 
destruction of leucocytes occurs. In general, then, an 
excess of uric acid is an indication of some nutritional 
disturbance. 

DISEASES IN WHICH URIC ACID IS INCREASED IN THE 

URINE. 

I. Fevers. 

II. Leukaemia. 

III. Diseases of the spleen. 

IY. Acute articular rheumatism, in which increase 
of uric acid is an unfavorable sign, and decrease a favor- 
able one. 

Y. Diseases of the lungs and heart, in which respi- 
ration is hindered (dyspnoea); also in ascites; large 
abdominal tumors. 

YI. Whooping-cough. 



PATHOLOGY OF URIC ACID. 99 

VII. Poisoning by carbonic oxide gas ; after alcohol- 
ic excesses. 

VIII. Inanition. 

IX. Cachexias in which there is great destruction of 
the corpuscle tissues. 

X. Extensive burns. 

XI. Some skin diseases, as lepra and eczema. 

XII. Chorea. 

DISEASES IN WHICH URIC ACID IS DECREASED IN THE 

URINE. 

In general those in which but little leucocyte forma- 
tion takes place, and where but slight destruction of 
them occurs : 

I. Chlorosis and anaemia. 

II. Osteomalacia. 

III. Disturbances of nutrition ; chronic lead-poison- 
ing. 

IV. After use of quinine and atropine. 

V. In chronic gout when the urates are deposited in 
the joints. 

VI. In arthritis, especially the gouty form. 

VII. In Irydruria and urina spastica. 

VIII. In chronic diseases of the spinal cord. 

CLINICAL NOTES. 

1. In diabetes mellitus uric acid is more often dimin- 
ished than increased. 

2. In the beginning of cirrhosis of the liver uric acid 
is increased ; in the stage of atrophy decreased. 

3. In interstitial nephritis uric acid is significantly 
decreased ; in chronic parenchymatous nephritis uric 
acid is much increased. 

4. Dr. J. W. Hunter, of Texas, reports a number of 
cases of asthma caused by uric acid, and cured by ap- 
propriate treatment. 

5. According to Drs. C. N. Fierce and E. C. Kirk, 
the morbific element in pyorrhoea alveolaris is uric acid. 

6. Haig speaks of a characteristic uric acid headache, 
which may be produced at will, and which is accom- 
panied by a very large excretion of uric acid. The 

LofC. 



100 URINARY ANALYSIS. 

headache, he holds, is due to increase of vascular tension 
caused by excess of uric acid in the circulation. 

7. Sutherland thinks that uric acid produces trouble 
in children with two classes of symptoms," those due 
to presence of uric acid in the system, and those due 
to excretion of it. In the former case catarrhal dis- 
orders are prominent, in the latter abdominal pains. 

8. According to Jaksch uric acid is not responsible 
for the acid intoxication of fever. 

9. Krauss, Pryor, Herter, and others believe that 
the pathogenic role of uric acid has been greatly exag- 
gerated. 

10. Levison regards it as proved that a simple excess 
of uric acid is not enough to cause lasting excess in 
the blood, but that there must also be a faulty elimin- 
ation by the kidneys. 

11. Haig in his latest work (1896) thinks uric acid 
a factor in the cause of high arterial tension, head- 
ache, epilepsy, mental depression, paroxysmal hemo- 
globinuria, and anaemia, Bright' s disease, diabetes, 
gout, and rheumatism. Kaynaud's disease and hys- 
teria are added to this list by others. 

12. E. E. Smith thinks that if the ratio of the urea 
and uric acid is expressed by a number above 45, the 
uric acid excretion is probably normal; while if it is 
expressed by a number below 40 there is good ground 
to believe that the excretion is in excess. 

CHEMICAL EXERCISE VI. 

Quantitative determination of uric acid The 

student having collected and measured his twenty - 
four hours' urine should determine the quantity of uric 
acid in it, using the method of Heintz, the simplest 
clinical method, as follows: 

Measure off 200 c.c. (7 fluidounces) of the twenty- 
four hours' urine, add to it 10 c.c. (one-third of a fluid- 
ounce) of hydrochloric acid. Let stand twenty-four to 
forty-eight hours in a cool, dark room. Collect the 
precipitated uric acid crystals on a previously weighed 

*See author's article in Tooker's "Diseases of Children," p. 464. 



PATHOLOGY OF URIC ACID. 101 

small filter, wash with cold distilled water, dry in dry- 
ing oven, {Fig. 29) and weigh. The difference in the 
weight of the filter before and after filtering represents 
the weight of uric acid in 200 c.c. of nrineal. If 
albumin is present, the urine should be acidulated with 
a few drops of acetic acid, boiled, and filtered, the 
filtered urine being used for the uric acid determination. 
Technique. — The above directions, given in several 
of our books, seem simple and easy to carry out, but 
there is a chance for various errors unless the follow- 
ing precautions are observed : 

1. Before weighing or filtering first dry the filter 
which should be done in the drving oven at a temper- 
ature of 100° C. (212° F.). 

2. After it ceases to lose weight, for which will be 
required about an hour's drying, h ^ c ~ —4 

record the weight. Use prefer- // ( / 

ably milligram weights [Fig. 30). * 

The small filters weigh from 550' Vj^f J^j 

to 750 milligrams when dry. \'\ @^- 

3. Fold the filter, insert into V 
the funnel, and filter the urine 
through it, being careful to save Fig. 30. Milligram 
the filtered urine. weights. 

4. Rub off the crystals of uric acid adhering to the 
dish by use of a glass rod, tipped with rubber tubing, 
and wash them into the filter, using filtered urine 
for washing purposes. 

5. Let the urine run completely through, then fill 
up the filter about two-thirds full with distilled water, 
using the wash bottle, and washing as thoroughly as 
possible with the amount of water used. This should 
not exceed 30 to 40 c.c. (about one fluidounce). 

6. After the water has run through, remove filter 
from the funnel with small pincers, being careful not 
to tear it, set it in a porcelain dish in the drying oven 
and dry it for several hours, if necessary, until it 
ceases to lose weight. 

7. Measure the amount of filtered urine plus wash- 
water, which will usually be 250 c.c, multiply the 



102 URINARY ANALYSIS. 

number of c.c. obtained by 48, and point off three 
places. The result is usually 12 milligrams. (Correc- 
tion of 4.8 milligrams for every 100 c.c. of urine, 
adopted by chemists on account of the solubility of 
uric acid in water). 

8. When the filter is dry, weigh it; subtract the 
weight obtained before filtering from the weight now 
obtained, and add 12 milligrams (or the result obtained 
in 7). The final result is in milligrams, the amount 
of uric acid in 200 c.c. of urine. Multiply by 5 to 
ascertain grammes per liter, pointing off three places; 
and multiply this product by the number of liters of 
the twenty -four hours' urine to get grammes of uric 
acid per twenty-four hours. 

Notes:— (1) According to Schwanert the uric acid crystals 
should be washed on the filter until a solution of silver nitrate 
gives no precipitate with the filtered wash-water. TIip writer has 
found that this precaution makes the results lower by about 4 
milligrams than when only 30-40 c.c. of water are used as above, 
that is, when the correction is made as in 7. Thorough washing 
with say 100 to 125 c.c. of water will take off 10 milligrams from 
the weight, but the correction, as in 7, will bring up the total. 

(2) Urine cloudy with urates should first be warmed before the 
hydrochloric acid is added. 

(3) Urines less than 1020 in specific gravity should be concen- 
trated over the water-bath until the specific gravity rises to that 
figure. 

Calculation of results: Suppose weight of dried filter before 
filtering is 750 milligrams. Suppose after drying again it is 820 
milligrams. Suppose the filtered urine and wash-water amount 
to 250 c.c. Then we have the following: 820 minus 75' > is 70 mil- 
ligrams; 250 times 48 divided by 1.000 equals 12 milligrams; 70 
plus 12 equals 82 milligrams of uric acid in 200 c.c. of urine. 
Then 82 x 5 equals 410 milligrams of uric acid in a liter (1000 c.c.) 
of urine or 0.4 gm. Suppose total urine in 24 hours is 850 c.c; 
0.4 gm. times 0.850 is 0.34 gm of uric acid in 24 hours. Turn now 
to Tables 6 and 7. We find 0.4 gm. per liter is just about normal, 
but 0.34 gm. in 24 hours is about two-thirds the usual normal 
average. Reduce to American measures by the Tables. Suppose 
total urea is 13.6 gm.; 13.6 divided by 0.34 equals 40. Ratio of 
urea to uric acid is 40 to 1 in this case. S( e Table 11. 

Note — Inasmuch as the term relative uric acid, relative phos- 
phoric acid, etc., are used by some German writers to mean the 
total quantity of uric acid, phosphoric acid, etc., compared with 
the total quantity of nitrogen, care must be taken to notice that 
the author uses this term always with reference to the quantity of 
water of the urine. When used in the sense the Germans use it, 
full explanation will be given. 



PATHOLOGY OF URIC ACID. 103 

Apparatus Required. 

1. Small filters, 5-6 centimeters (about two inches) in diameter. 

2. Chemical balance {Fig. 31.) 




Fig. 31. Chemical balance. 




Fig. 29. Drying oven. 

8. A drying oven, (Fig. 29.) 

4. A glass rod tipped with rubber tubing. 

5. An evaporating dish holding 200 c.c. (half- a- pint) of urine. 
{Fig. 27.) 

Note: — Unless what is called rapid filtering paper is used, the 
operation according to Schwanert's directions is a very slow one 
requiring several hours unless a filter-pump is at hand. 



104 URINARY ANALYSIS. 



CHAPTER XIY. 

SUBSTANCES RELATED TO URIC ACID. 

The substances of minor clinical importance related 

to uric acid are, in alphabetical order, as follows : 

Allantoin; Kreatin; Kreatinin; Xanthin, and allied substances. 

These substances all contain nitrogen, and together 

with urea and uric acid, are the means by which this 

important element is excreted in the urine. 

Allantoin, or glyoxyldiureid, C 4 H fl N 4 O s , an organic substance, 
occurs in the urine of children within the first eight days after 
birth. In small amounts in the urine of grown persons; rather 
abundantly in that of pregnant women. 

Related to uric acid. Formed by oxidizing uric acid with lead 
peroxide. Colorless prisms soluble in hot water, slightly in cold, 
insoluble in alcohol and ether. Precipitated by mercuric salts. 

Detection: Precipitate urine with baryta water, filter, remove 
baryta with sulphuric acid, filter, precipitate the allantoin with 
mercuric chloride in alkaline solution, decompose precipitate with 
sulphuretted hydrogen, concentrate strongly, purify the crystals 
by recrystallization. 

Kreatin.— This organic substance, C4H4X3O, one of the nitrog- 
enous substances of urine, occurs normally in alkaline urine in 
greater quantity. In acid urine kreatinin appears in greater 
quantity. Kreatin is easily transformed into kreatinin, which see. 
Also converted by certain germs into methylguanidin, which causes 
symptoms resembling uraemia. 

Kreatinin. — Important because of the nitrogen it 
contains. 

Chemical constitution, C 4 H 7 N 3 0, or NH=C<C^(^? >CH 2 , 
an anhydride of kreatin, one of the strongest bases in the body. 

Form. — Crystallizes in large colorless prisms. (See 
Sediments. ) 

Occurrence. — Constantly in solution in the urine. 

Solubility. — Easily soluble in water, hence rarely 
in the sediment. Less soluble in alcohol. Insoluble 
in ether. 

Properties. — Alkaline in reaction, converted by 
bases into kreatin. Combines with both acids and 
salts. A characteristic compound of the latter class is 



SUBSTANCES RELATED TO URIC ACID. 105 

Jcreatinin- chloride of zinc (C 4 H T K,0) 8 ZnCl a , diffi- 
cultly soluble in water. 

Kreatinin has strong reducing properties, as on 
Trammer' s and Fehling's test-liquids, but not on 
alkaline bismuth solutions. 

Tests. — (1) Add to the urine a few drops of freshly- 
prepared very dilute solution of nitroprusside of sodium 
and, afterward, a few drops of dilute sodium hydrox- 
ide solution, when a red color appears which changes 
to yellow on standing. Now add acetic acid in excess, 
and heat, when a greenish, then blue color appears, 
and finally a precipitate of Berlin blue. 

(2) Add to the urine a little picric acid solution and 
a few drops of dilute sodium hydroxide solution, when 
a red coloration appears, which lasts for an hour, and 
changes to yellow on addition of acid (glucose gives 
this red color on warming). (For quantitative deter- 
mination, see Appendix.) 

Physiology. Kreatinin has its origin in the muscles, 
being formed from the kreatin of them. The change 
probably takes place in the musole. Bunge thinks 
muscle kreatinin ultimately converted into urea and 
urine kreatinin derived from the food. The average 
quantity in the urine per twenty-four hours is 0.6 to 
1.3 gramme, the most on an exclusive meat diet. 
It is diminished by fasting. 

Pathology. Increased in acute diseases, especially 
in pneumonia, typhoid, and intermittents; also in some 
cases of diabetes mellitus. Diminished in convales- 
cence from acute diseases, in advanced Bright' s, and 
in tetanus ; also in diseases characterized by muscular 
wasting. (See also Sediments.) 

Xanthin bodies. — These are xanthin, hypoxanthin, 
carnin, adenin, paraxanthin, and heteroxanthin. Or- 
ganic, related to uric acid. Thus, uric acid C 6 II 4 N 4 O s , 
xanthin C 6 H 4 N 4 0,. Xanthin occurs in very small 
quantity in human urine, according to Neubauer, 1 
gramme in 300 liters. The xanthin bodies are almost 
insoluble in water, unite with bases, acids, and salts, 
are precipitated by ammoniacal silver solutions like 
uric acid, and give at red-heat, like uric acid, the odor 



106 URINARY ANALYSIS. 

of hydrocyanic acid. Xanthin is insoluble in alcohol 
and ether, readily soluble in alkalies, and also in dilute 
nitric and hydrochloric acids. It sometimes occurs as 
a deposit (see Sediments), and is a constituent of a rare 
form of calculus, found always in case of young 
persons. 

Detection. — Remove albumin from the urine by 
boiling and filtering, and treat the urine inter- 
mittently with phospho-tungstic acid, and hy- 
drochloric acid, until no more precipitate takes 
place. The precipitate is allowed to settle for twenty- 
four hours, then washed with dilute sulphuric acid 
(5 :100) by decantation till free from chlorine, filtered 
and treated with excess of barmin hydroxide and 
application of heat to remove uric acid. The filtrate 
is precipitated with ammoniacal solution of silver, and 
the precipitate which contains the xanthin bases is 
washed. Dissolved in dilute hydrochloric acid hexa- 
gonal crystals of xanthin separate on evaporation. 
Evaporated to dryness with nitric acid a yellow resi- 
due remains, which turns red with caustic potash 
solution, and reddish violet when heated. (For 
quantitative determination see Appendix). 

Pathology : The pathology of xanthin, paraxan- 
thin, etc., has been experimentally investigated 
by B. K. Rachford (Medical Record, 1895). He 
calls these bodies uric acid leucoma'ins, and asserts 
that paraxanthin and xanthin are etiologically related 
to a group of nervous disorders which are manifesta- 
tions of leucoma'in poisoning. The three clinical forms 
of the auto-intoxication are as follows: 1, A true 
migraine or leucoma'in headache ; 2, a migrainous epi- 
lepsy, or leucomain epilepsy; 3, a migrainous gastric 
neurosis, or leucoma'in gastric neurosis. Paraxanthin 
is by far the most poisonous of all leucomai'ns, xanthin 
is much less poisonous. His conclusions are as fol- 
lows: 

"1. Paraxanthin and xanthin are poisonous leuco- 
mains of the uric-acid group, capable of producing the 
most profound nervous symptoms. They are readily 
soluble in water, urine, and blood. 



SUBSTANCES RELATED TO URIC ACID. 107 

"2. Paraxanthin is found in normal urine in such 
small quantities that its poisonous properties are lost 
in dilution. Salomon found only 1.2 gm. in 1,200 
liters of urine. This quantity is so minute that its 
presence cannot be satisfactorily demonstrated in such 
quantities of normal urine as can conveniently be ob- 
tained from patients. In a recent personal communi- 
cation Salomon says : ' Nine liters of urine is a very 
small quantity to prove the presence of paraxanthin, 
if one has not previously worked with larger quantities 
so as to master the details of the work, and very much 
harder would it be to prove the presence of paraxan- 
thin in four liters of normal urine, as I know from ex- 
perience. ... I would advise that not less than 
ten liters of normal urine be used to demonstrate the 
presence of paraxanthin.' My own experience is in 
accord with Salomon's. In previous papers I have 
recorded my failure to demonstrate the presence of 
paraxanthin when working with as little as four liters 
of normal urine ; and since these papers were written 
I have made a large number of examinations of normal 
and other urines, and I have always failed to demon- 
strate the presence of paraxanthin in four liters of nor- 
mal urine. Upon this evidence I have concluded that 
paraxanthin is present in abnormally large quantities 
when I can find it in less than four liters of urine. 
Xanthin also, as a rule, requires more than four liters 
of urine to demonstrate its presence, but I have fre- 
quently found small quantities of xanthin where I 
could not find paraxanthin in working with four liters 
of urine. 

<; 3 Paraxanthin and xanthin are not formed in the 
kidney. They are excreted from the blood by the 
kidneys. The presence, therefore, of large or small 
quantities of xanthin bodies in the urine means that 
these bodies were present in large or small quantities 
in solution in the blood previous to their elimination 
by the kidneys." (Rachford.) 

4. In certain cases of migraine paraxanthin and 
xanthin are excreted in great excess during the at- 
tacks, but not in the intervals. 



108 URINAR Y ANAL YSIS. 

5. In the study of a case of migrainous epilepsy the 
following was ascertained by him : During the attack 
the patient excreted a quantity of paraxanthin and 
xanthin enormously in excess of normal, but during 
the interval between the attacks not enough paraxan- 
thin was excreted to be detected in three liters of 
urine. The paraxanthin excreted in such large quanti- 
ties just following these attacks must have been in 
solution in the blood during the paroxysms. 

6. In a case of migrainous gastric neurosis the quan- 
tities of xanthin and paraxanthin in the urine during 
the attacks, were enormously increased, two liters of 
urine being enough to allow separation of both bodies 
Two minims of "final fluid," 3 c.c. in volume, thrown 
into the muscles in the back of a mouse produced death 
in from 15 to 30 minutes. In four liters of urine 
between the attacks no paraxanthin was found and 
the final fluid w T as not poisonous to mice. 

See Appendix for the process of isolation and 
detection. 



AROMATIC COMPOUNDS. 109 



CHAPTEK XV. 



AROMATIC COMPOUNDS IN THE URINE. 

The aromatic compounds in urine may be classified 
as follows : 

I. Aromatic compounds of glycocin, as hippuric 
acid. 

II. Glycuronic acid combinations with aromatics. 

III. Uncombined aromatic substances. — As cumarin, 
hydroparacumaric acid, etc. 

TV. Ethereal sulphates as phenol -sulphuric acid, 
indoxyl-sulphuric acid, etc. 

Hippuric acid, C g H 9 N0 3 , H(C 9 H 8 N0 3 ), a monobasic organic 
acid occurs in small amounts, 0.7 gramme daily in normal urine. 
By diet rich in fruits and vegetables as cranberries, prunes, plums, 
etc., it may be increased to two grammes (31 grains). 

Chemical constitution. — Chemically hippuric acid is benzoyl 
glycocoll, 

CH 2 .NH(C,H,CO) 

COOH, 
and is a derivative of benzoic acid, from which it may be formed 
within the body by oxidation, when benzoic acid, or a number of 
other substances, is taken internally. 

Origin. Not definitely ascertained. 

Phenyl-propionic acid produced in the body during the process 
of intestinal putrefaction is absorbed into the blood and thought 
to be transformed there into benzoic acid (phenyl-formic acid). 
Benzoic acid coming into contact with glycocoll, a substance 
probably produced during intestinal putrefaction, probably forms 
hippuric acid according to the equation 

C.H, + CH 2 NH 9 = CH 2 NH(C 6 H 6 CO) -f H,0 

COOH COOH COOH 

Benzoic acid Glycocoll Hippuric acid. 

Solubility. It is soluble in 600 parts of cold water, easily solu- 
ble in hot water, readily so in hot alcohol and ether, insoluble in 
petroleum-ether, and benzene; soluble in ammonia water, insolu- 
ble in hydrochloric acid. 

Occurrence. In solution in all normal urine and occasionally in 
the sediment. (See Sediments). 

Physical characteristics. Colorless, odorless, of slightly bitter 
taste. 

Form. When obtained from urine or made synthetically, it 
forms fine needles or vertical rhomboid prisms. According to 
Heitzmann the prisms in urine often show indentations. (See 
Sediments). 



HO URINARY ANALYSIS. 

Detection. Evaporate the urine with nitric acid, heat residue 
dry in a test tube, and an odor like oil of bitter almonds indicates 
presence of hippuric acid. More conclusive is the following: 
Make the urine alkaline with sodium carbonate, concentrate by 
evaporation as much as possible, and extract the residue with 
absolute alcohol. The alcohol is evaporated, the remaining mass 
dissolved in water, the solution made acid with sulphuric acid 
and extracted with five fresh portions of acetic ether by shaking 
repeatedly. The ethereal extract is several times washed with 
water, then freed from the latter and evaporated at moderate 
temperature. The hippuric acid is now freed from benzoic acid, 
fat, and the like by washing with petroleum-ether, dissolved in 
a little warm water, and the solution evaporated at about 50° C. 
(122° F.) to crystallization. The crystals are then collected and 
weighed. 

Micro-chemical detection. If the urine contain excess of hip- 
puric acid, the latter may be detected by evaporating slightly, and 
feebly acidulating with hydrochloric acid. On standing a few 
hours hippuric acid crystallizes out and may be recognized by the 
microscope. (See sediments). 

Physiology : Hippuric acid in the organism owes its 
origin to the oxidation of albumin, and its quantity 
depends on the degree of albumin decomposition in 
the intestine. It is present in comparatively large 
amount in the urine of herbivora, much less in that of 
omnivora, and absent in the urine of carnivora. It is 
increased by vegetable diet and by such fruits as cran- 
berries, etc., already mentioned. It is also increased 
by administration of benzoic acid, oil of bitter almonds, 
toluol, cinnamic acid, benzylamin, phenylpropionic, 
and kinic acid. It is decreased by an animal diet but re- 
mains in small quantities even on an exclusive meat diet. 

Pathology : Increased in acute febrile processes, 
diseases of the liver, chorea, diabetes mellitus. (See 
Sediments). 

Decreased in amyloid degeneration of the kidneys. 

In acute and chronic parenchymatous nephritis ad- 
ministration of benzoic acid does not result in elimina- 
tion of hippuric acid. 

Grlycuronic Acid Combinations:— Small quantities of this or- 
ganic substance in combination with aromatics occur in the urine. 
Normally it occurs in very slight traces, hence will not be con- 
sidered here. See Abnormal Constituents. 

Cumarin: — An organic aromatic substance said to occur in urine. 

Hydroparacuniaric acid: — One of the uncombined aromatic 
substances, C 6 H 4 (OH)CH 2 .CH 2 COOH, produced by the decay of 
tyrosine. Organic. 

Oxyphenylacetic acid is another one of the uncombined aro- 
matic substances occurring in urine. 



AROMATIC COMPOUNDS. Ill 

Ethereal sulphates. — The ethereal sulphates in 
urine are combinations of sulphuric acid with phenol, 
parakresol, pyrocatechin, indoxyl, and skatoxyl. 
They contain the radical HS0 3 and are incorrectly 
called sulphonates. Also called sulpho- conjugated 
acids, or conjugate sulphates, sometimes also aromatic 
sulphates. 

They are derived in small part from aromatic sub- 
stances in the food, being chiefly due to putrefactive 
changes in the intestine. They serve as a guide to us 
of the amount of putrefaction in progress within the 
body, and are also of diagnostic importance when we 
wish to determine whether febrile diseases, exanthems, 
etc. , depend on intestinal processes, or whether mel- 
ancholia is a sequence of intestinal disturbance. 

Increase of ethereal sulphates takes place in deficient 
absorption of normal products of digestion, as in peri- 
tonitis and intestinal tuberculosis; in fermentative 
diseases of the stomach ; in putrefactive processes out- 
side the alimentary canal, as in putrid cystitis, ab 
scesses, peritonitis, etc. Discharge of putrid matter 
diminishes the quantity. As no simple clinical method 
is known for quantitative determination of them, see 
Appendix for complete process. 

Test. — To test for the conjugate sulphates 25 c.c. of 
urine are treated with about the same volume of an 
alkaline barium chloride mixture (2 volumes of a solu- 
tion of barium hydrate and 1 volume of a solution of 
barium chloride both saturated at ordinary tempera- 
tures) and filtered after a few minutes, the mineral 
(preformed) sulphates as well as the phosphates being 
thus removed. The filtrate is then strongly acidified 
with hydrochloric acid and boiled, when the occur- 
rence of a precipitate will be referable to conjugate 
sulphates. 

In the quantitative method (see Appendix), the same 
procedure is followed and the precipitate being filtered 
off is washed, dried, and weighed. 

Significance. — The normal ratio of the mineral 
(preformed) sulphates to the ethereal sulphates is 10 
to 1. This ratio may be enormously decreased in 



112 URINARY ANALYSIS. 

coprostasis, the result of carcinoma, as low as 2 to 1 
having been observed. C. E. Simon has seen the 
ratio 1.5 to 1 in a case of volvulus of ten days' 
standing. 

The degree of intestinal putrefaction may he meas- 
ured directly by the elimination of the ethereal sul- 
phates: — Increased degree of intestinal putrefaction 
accompanies diminution of secretion of hydrochloric 
acid by the stomach, and vice versa. 

In obstructive jaundice Simon has noticed an increase 
of the ethereal sulphates, while in non- obstructive 
jaundice the total sulphates (mineral and ethereal) were 
decreased. 

In diarrhoea the total sulphates were diminished, 
likewise the ethereal sulphates, while the ratio of the 
mineral to the ethereal increased. Terpenes and 
camphor cause a decrease in the excretion of the 
ethereal sulphates. Carlsbad and Marienbad waters 
at first cause an increase but subsequently a decrease 
of the ethereal sulphates. Kefir, in doses of from 1 
to 1.5 liters a day, has proved an excellent remedy 
for checking intestinal putrefaction. 

John A. Wesener of Chicago deserves mention for 
original work in connection with the ethereal sulphates 
and, in view of the rather scanty space in text- books 
which is accorded most investigators on this side of 
the water, we insert his paper almost in full : 

The literature of the aromatic sulphates has been summed up 
by Wesener as follows: Baumann noticed in a patient with a 
fistula in the upper part of the small intestine, that urine during 
the time in which the intestinal contents did not pass out by the 
natural means, showed a considerable diminution of aromatic sul- 
phates, containing only traces of phenol and indol. When this 
fistula was closed and the intestines restored to their normal func- 
tion, it was noticed that the elimination of the aromatic sulphates 
was increased very much. An exactly similar case was reported 
by Ewald. These observations go to show that in the jejunum a 
ceitain number of aromatic combinations are produced by the 
action of micro-organisms and the intestinal juices on the food 
Baumann and Wasliff found a decrease of aromatic sulphates in 
the urine of starving dogs, and an entire absence of the same 
after the intestine had been disinfected by large doses of calomel 
given several consecutive days. It might be well to mention here 
the researches of Ortwiler, who ascertained that in febrile diseases 
not involving the intestinal tract, which are accompanied by 



AROMATIC COMPOUNDS. 113 

destructive tissue changes, there is no increase of indican in the 
urine. 

If these aromatic combinations are not products of intestinal 
decay, then why do we not find them in the muscles and healthy 
organs? All investigations have failed to show their presence 
there, while on the other hand the intestinal discharges of starv- 
ing animals always show the presence of considerable indol; fur- 
thermore, it has been proved by Kiihne and Nencke that indol 
is exclusively a product resulting from the action of bacteria on 
albuminoids. If we consider that micro-organisms do not occur 
in the tissues of healthy organs, as has been conclusively proved 
by Meisner, Zahn, and Henser, we must necessarily come to the 
conclusion that the formation of aromatic combinations in the 
organs outside of the intestinal tract is, under physiological con- 
ditions, out of the question. 

Salkowski has shown that there is an increase of indol and phe- 
nol in the urine of patients who suffer from ileitis and peritonitis. 
Brieger has shown that in chronic anaemia and in cachexia there 
is much indoxyl and little phenol in the urine ; whereas in diseases 
of the stomach there is an increase of phenol, leading one to infer 
that free HC1 is a large factor in lessening putrefaction. 

He found an increase of phenol in tuberculosis of the periton- 
aeum, acute peritonitis with constipation, empyema of the lungs, 
septic and puerperal fevers, diphtheria, erysipelas, etc. He con- 
cludes from this that phenol shows either increased decomposition 
of the contents of the intestine or the presence of a putrid area in 
the body. 

Jatfe found an increase of indoxyl in diseases ot the small intes- 
tines; a decrease in dysentery, pathological conditions of the large 
intestine, stomach, and duodenum. 

Senator reports an increase of indol in chronic wasting diseases 
— such as malignant lymphoma, chronic peritonitis, and cancer 
of the stomach. 

The writer of this paper (Wesener) has found the aromatic com- 
binations greatly increased in one case of pernicious anaemia and 
in a number of chlorotics. It may be said here, before admin- 
istering iron to these cases, it is absolutely necessary to disinfect 
the intestinal canal. 

Heninge says that a large amount of indoxyl is present in the 
urine of pernicious anaemia, typhus, cholera, chronic suppuration, 
progressive atrophy of muscles, and Addison's disease. He 
attributes it in part to the increased separation of the constituent 
of the albuminoids and in part to an increase in the amount of 
pancreatic juice. 

Hoppe-Seyler, as a result of exact clinical investigation, has 
come to the conclusion that in general the excretion of these 
bodies goes hand and hand with an increase of those processes 
which impair the digestion in the small intestine. The investiga- 
tions of Hirschler, T. R. Miiller, Helden and others show that the 
aromatics are diminished in the urine when the albuminoids are 
excluded from the food and a large amount of carbjhydrates is 
used instead. As a result of these observations we can see that 
the derivatives of the aromatic series appear in the urine under 
physiological conditions as the result of the putrefaction of sub- 
stances containing water. 
15 



114 URINARY ANALYSIS. 

Ortwiler found that bismuth subnitrate in large doses had no 
effect on intestinal putrefaction; large doses of castor oil produced 
an increase of the aromatic sulphates. Kast ascertained that 
neutralizing the stomach with large doses of alkaline carbonates 
had a very decided and lasting effect in the increase of aromatic 
sulphates; in hyperacidity of the stomach the aromatic sulphates 
were diminished. 

Morax, in his experiments performed upon animals, found that 
calomel and iodoform diminished the aromatic sulphates, whereas 
ordinary doses of calomel given to human beings did not act as 
an intestinal disinfectant. 

Rovighi found that large doses of the terebene group and cam- 
phor given to animals diminished the putrefaction to a consider- 
able extent; these compounds administered to healthy persons had 
very little effect. 

Biernecky found that on an exclusive milk diet the aromatic 
sulphates diminished one-half in twenty-four hours. 

Winternitz, by his experiments, has proved that albuminous 
putrefaction is greatly lessened in the presence of milk sugar, 
glycerine, and lactic acid. He found that on adding a large 
quantity of milk to beef extract, albuminous putrefaction was 
greatly diminished. 

In experiments performed with dogs, who were first fed on 
meat, then on a milk diet, it was found that in the former the 
aromatic sulphates were three times and a half as high as when 
the latter was given. 

According to Carl Schmit, milk sugar is the compound in milk 
which prevents intestinal putrefaction. He fed dogs on meat and 
milk sugar, and the aromatic sulphates were greatly lessened. 

The writer ( Wesener), in order to determine whether casein or 
milk sugar is the compound which disinfects the small intestine, 
undertook the following experiment: Casein was precipitated 
from milk and then washed with hot alcohol until all milk sugar 
was removed. This diet was given for three days, the total 
twenty-four hours' urine being saved; the aromatic sulphates 
were not diminished. When albuminoids are removed from the 
food and carbohydrates substituted, the putrefaction is diminished 
largely; this result is brought about in all probability by the 
starvation of those bacteria which live upon proteids. It is very 
probable that in the course of intestinal putrefaction there are, 
besides the aromatic compounds, other unknown chemical combi- 
nations which are, perhaps even more poisonous than the former. 
Observations have shown that more aromatic sulphates are 
excreted during the day than during the night. If the subject for 
experiment receives no water, and we examine the urine, we find 
the aromatics lessened. It appears from this that drinking causes 
an increase of the aromatic sulphates, and it is therefore neces- 
sary in ascertaining* the amount of aromatics excreted to 
figure on the total amount of the urine that has been passed 
during twenty-four hours. 

Wesener' s conclusions are as follows: 

1. Saline cathartics at first increase the aromatic 
sulphates, then decrease them. 



AROMATIC COMPOUNDS. 115 

2. Calomel in large doses for two or three days 
slightly diminishes them. 

3. Oil of eucalyptus given for three to four days 
diminishes them. 

4. Kumyss reduces putrefaction to a minimum, 
diminishing the aromatic sulphates 85 to 100 per cent. 

Chas. E. Simon, of Baltimore, in his excellent work 
on "Clinical Diagnosis" summarizes in regard to the 
ethereal (conjugate) sulphates as follows : 

1. An increase in the conjugate sulphates in a gen- 
eral way points to increased intestinal putrefaction, 
the direct cause for which must, according to our 
present knowledge, be sought in a total anachlorhydry, 
or at least a hypochlorhydry of the gastric juice, asso- 
ciated with intense bacterial fermentation, provided 
that lactic acid and butyric acid are not present in 
large amounts ; an obstruction to the flow of bile and 
intestinal obstruction may, however, produce the same 
result. 

2. A diminution in the quantity of conjugate sul- 
phates, on the other hand, may be referable to hyper- 
cblorhydry associated with torular fermentation, ulcer 
of the stomach forming an exception, in which, not- 
withstanding the fact that conjugate sulphates are 
frequently eliminated in increased amount, hyper- 
chlorhydry usually exists. 

3. In cases of diarrhoea the absolute as well as the 
relative quantity of total sulphates and of conjugate 
sulphates is diminished, while the ratio of the mineral 
sulphates to the conjugate becomes greater. 



116 URINARY ANALYSIS. 



CHAPTER XVI. 



THE AROMATIC COMPOUNDS— CONCLUDED. 

The remaining aromatic compounds to be considered 
are : 

INDOXYL-SULPHURIC ACID (INDICAN), PHENOL-SULPHURIC ACID, 
ETC. 

INDOXYL-SULPHURIC ACID. 

Nomenclature: — This substance is usually, though 
incorrectly, called indican, being thought to be identi- 
cal with vegetable indican, which is a glucoside. The 
substance occurring in the urine is, however, an 
ethereal (conjugate) sulphate. 

Synonyms: — German, Indoxyl-schwefelsdure, Har- 
nindican' French, indican. 

Clinical constitution: — Potassium indoxyl-sulphate, 

C«H 8 NO.KS0 3 or SO z <^ eNO a conjugated sul- 

pho-acid salt of potassium. 

Origin in the body: — Indol formed during the pro- 
cess of intestinal putrefaction is oxidized to indoxyl in 
the blood, thus : 

C 8 H 7 N + O = C 8 H 7 NO 

Indol Indoxyl. 

Indoxyl combining with sulphuric acid forms in- 
doxyl-sulphate according to the equation 

8 H ? NO + SO z <°g = S0 2 <^» N0 + H 2 

Indoxyl Sulphuric acid Indoxyl sulphate Water. 

Indoxyl-sulphate and dipotassic hydrophosphate are 
eliminated in the urine as indoxyl-potassium sulphate 
and potassium clihydrophosphate as follows : 

K 3 HP0 4 + SO,<^ 6]STO = KH P0 4 + 

so aH 8 NO 
DU ^OK 



AROMATIC COMPOUNDS.- INDIC AN. 117 

Occurrence: — In solution in the urine- 
Form: — When isolated as potassium indoxyl-sul- 
phate, it occurs in white tablets and plates. Obtained 
from urine it is a clear, brown syrup. 

Solubility: — Soluble in water, sparingly in alcohol. 
Effect of oxidation: — By oxidation of indoxyl- 
potassium sulphate indigo-blue is formed and the blue, 
green, and some red tints of urine in disease are prob- 
ably derived from different stages of oxidation of this 
substance. A. bluish-red pellicle may often be seen in 
decomposing urine consisting of microscopic crystals 
of indigo- blue and red, formed from decomposition of 
the substance. (See Sediments). 

Ord has described a calculus composed of indigo. 
Tests: — 1. The most convenient test is Stokvis's 
modification of Jaffe's well-known test: Mix a few 
c.c. of the whole 24 hours' mixed urine with an equal 
volume of concentrated pure hydrochloric acid. Add 
2 or 3 drops of a strong solution of sodium hypo- 
chlorite, calcium hypochlorite, or common saltpeter, 
and 1 or 2 c.c. of chloroform. Shake the mixture 
thoroughly, and set aside. The chloroform is colored 
blue by the indigo set free from the indican, and the 
intensity of the color compared with a 24 hours' 
normal specimen shows the degree of increase of 
indican. 

Note:— Since methods for the quantitative determination of 
indican, except by the spectroscope, are inaccurate, lengthy, and 
complicated, they will not be described here The method given 
above, if used systematically, on the same quantity of urine in 
each case and with the same quantity of reagents each time, 
enables the physician to judge of the degree of increase fairly 
accurately. 

In performing the above test bile-pigment, if pres- 
ent, must be removed by careful addition of a solution 
of subacetate of lead (avoiding excess) and filtration. 
Yery dark urines should be treated in the same way. 
Urine to be tested for indican should not contain 
potassium iodide, as the iodine set free on addition of 
acid will color the chloroform. Albumin does not 
interfere with the test. 



118 URINARY ANALYSIS. 

2. Keilmann's test:— Equal parts of urine and strong hydro- 
chloric acid are shaken together and a little chloroform added. 
In presence of indican the chloroform becomes blue and falls to 
the bottom of the tube. Add, drop by drop, a 5 per cent solution 
of calcium hypochlorite, and judge of the amount of indican 
present by the number of drops of hypochlorite necessary to 
decolorize it. Three or four drops may be enough, but in some 
cases 50 to 80 are required. 

3. Marten's test: — Warm the urine and add yellow nitric acid, 
when a dark brown color appears becoming black on further 
addition of acid. 

4. The spectroscopic method of McMunn:— Equal parts of 
urine and hydrochloric acid with a few drops of nitric acid are 
boiled together, cooled and shaken with chloroform. The latter 
is colored violet, and shows an absorption band before D, due to 
indigo-blue, and another after D. due to indigo-red. 

Physiology: — The chemistry of its origin in the 
body has already been considered. Indol is a specific 
product of albuminous putrefaction in the presence of 
organized ferments. Indican being derived from in- 
dol, micro-organisms are always concerned in the pro- 
duction of indican and, in health, the large intestine is 
its only source. 

The quantity eliminated normally in the urine varies 
with the kind of diet, 6.6 milligrams per liter being 
the average of eight observations of Jaffe. Red meats 
increase it, milk or kumyss decrease it. The urine of 
new-born children does not contain it. Starvation 
increases it, since secretions rich in albumin putrefy in 
the intestine. 

Pathology: — Indican is increased in the urine in the 

following : — 

1 . Whenever there is an increase of intestinal putre- 
faction as in anachlorhydry, hypochlorhydry ; in car- 
cinoma of the stomach; in acute, subacute, and chronic 
gastritis ; also in ulcer of the stomach, although hyper - 
chlorhydry may simultaneously occur. 

Note: — Hypochlorhydry the secretion of a deficient amount of 
free hydrochloric acid, less than 0.1 per cent; anachlorhydry, ab- 
sence of hydrochloric acid; hyperchlorhydry, excessive secretion, 
more than 0.2 per cent 

2. In conditions in which the peristaltic movements 
of the small intestines have become impeded : ileus, 
acute and chronic peritonitis, no matter what the state 
of the gastric juice is. 



AROMATIC COMPOUXDS.—IXDICAX. 119 

3. In diseases in which, in general, abundant albu- 
minous putrefaction is progressing in some part of 
the body, as pleurisy with abundant unhealthy exuda- 
tion, peritonitis with formation of putrid pus, fetid 
bronchitis, multiple lymphoma, emp} T ema, gangrene 
of the lungs. In such cases phenol- sulphuric acid 
may be more abundant relatively in the urine than 
indican. 

4. In a number of diseases as Addison's, cholera, can- 
cer of the liver, chronic phthisis, central and peripheral 
diseases of the nervous system, typhoid fever, dysen- 
erty, diabetes mellitus, trichiniasis, paraplegia, long 
standing suppurations. In the majority of these C. 
E. Simon holds that the indicanuria is merely an 
index of the condition of the gastric juice. 

5. After use of certain drugs as turpentine, oil of 
bitter almonds, nux vomica, and creosote. 

CLINICAL NOTES. 

1. Dr. C. E. Simon, of Baltimore, has studied the 
relation between indican (indoxyl sulphuric acid) and 
the acidity of the gastric juice. His conclusions 
are as follows : 

1. The gastric juice possesses antiseptic and germicidal 
properties. 

2. These properties are referable to the presence of free hydro- 
chloric acid. 

3. \ subnormal amount of free hydrochloric acid will call forth 
an increased degree of intestinal putrefaction. 

4. The conjugate sulphates form an index of the degree tif 
intestinal putrefaction. 

o. The increased intestinal putrefaction in cases of subacidip 
and anacidity of the gastric juice is largely referable to an 
increased formation of indol. 

6 The elimination of indican in the urine may be regarded as 
an index of the amount of free hydrochloric acid present. 

7. A normal acidity of the gastric juice is never associated 
with increased indicanuria. 

8 Cases of ulcer of the stomach apparently form an exception 
to this rule, an increased indicanuria being usually associated 
with hyperchlorhydry. 

9. In oth^r cases of hyperchlorhydry a subnormal or normal 
amount of iudican is eliminated. 

1<>. Simple constipation is rarely accompanied by an increased 
elimination of indican. 

11. Diarrhoea referable to a catarrhal condition of the colon, 
often following a previously existing coprwstasis, as well a^ 



120 URINARY ANALYSIS. 

diseases of the colon in general, is not associated with an increased 
indicanuria. 

12. In the differential diagnosis between ileus and coprostasis, 
a small amount of indican excludes the former condition. 

13. In cases of an achlorhydry with much lactic acid, the indi- 
can is not necessarily increased. 

14. No indican, or but little indican, with delayed Gunzburg 
potassium-iodide reaction, indicates the absence of free hydro- 
chloric acid, with much lactic acid. (The Gtinzburg test is for 
free HC1 in the stomach.) 

15. Much indican. with a normal or anticipating Gunzburg 
reaction, is suggestive of ulcer. 

16. In cases in which the use of the gastric tube is impractic- 
able or contra-indicated, or in cases of a mere superficial examina- 
tion, the indican reaction will furnish a valuable index of the 
condition of the patient's digestive powers 

17. By means of the indican reaction we are enabled to fellow 
very closely the results of treatment instituted in cases of gastro- 
intestinal disease. 

Given as premises: 

1. That a resorption of decomposing pus is not taking place 
anywhere in the body, as such a process itself is capable of pro- 
ducing an increased elimination of indican. 

2. That there does not exist a stenosis of the small intestine. 

3. A normal mixed diet containing no excessive amounts of 
red meats. 

Note:— Simon finds that a large quantity of indican may be 
of decided value in differential diagnosis of ileus, since diseases of 
the large intestine alone are never associated with an increase in 
the amount of indican. 

2. Suppuration may be suspected as taking place in 
the body if, after administration of intestinal dis- 
infectants (naphthol, bismuth), indicanuria still per- 
sists. 

3. Fahn finds indican increased in tuberculosis. 

4. Herter finds indicanuria (1) in chronic intesti- 
nal dyspepsia with clay-colored stools and mental de- 
pression, (2) in neurasthenia from sexual excess, (3) in 
chronic constipation, (4) in chronic epilepsy, especially 
after the attacks. 

Marten out of 6 cases of indicanuria found in all but 
one some intestinal trouble or other. The exception 
was a drunkard subject to fits. 

6. According to C. E. Simon, examination of the 

urine for indican is at least as important as that for 

albumin and sugar 

Skatoxyl-Sulphuric acid: — Formula, C 9 H 8 N.O.S0 2 .OH, an 
aromatic substance, ethereal {conjugate) sulphate, found in normal 
urine. It resembles indican in that it is an organic product of the 
decomposition of albumin. 






AROMATIC COMPOUNDS.— PHENOL. 121 

Test: — Jaffe's test for indican, when performed on urine rich in 
skatoxyl, shows a dark- red to velvet color on addition of hydro- 
chloric acid. If nitric acid be used, a cherry-red color is de- 
veloped; if hydrochloric acid, ferric chloride, and heat are used 
a red color occurs, which can be removed from the fluid by ether 
or acetic ether, while on heating with zinc dust skatol is liberated. 

Significance: — It is found in very small quantities in normal 
urine and its significance is said to be much the same as that of 
indican, so far as increase goes. Urines rich in skatoxyl darken 
on exposure to the air, as in carboluria, while at the same time 
they take on from the surface a reddish or velvet color, often al- 
most black. 

Phenol-Sulphuric Acid:— Formula, C 8 H B O.SO a .OH, anorganic 
aromatic substance, ethereal or conjugate sulphate, found in 
very small quantity in the urine. The phenol is a product of 
intestinal fermentation, and some of the sulphate is derived from 
tyrosine. 

Detection: — Acidulate the urine with sulphuric acid and distill. 
Add (a) bromine-water to distillate and a deep-yellow precipitate 
of tribromphenol appears, if phenol is present. Or (b) warm the 
distillate with Millon's reagent, and a cherry-red color appears. 

Note: — Millon's reagent is made by dissolving 10 grammes of 
mercury in 20 grammes of nitric acid (sp. gr. 1.42) and diluting 
with 20 c.c. of water. 

A third test (c) may be tried by adding ferric 
chloride solution to the distillate, when a deep violet 
color appears. 

Significance: — Phenol-sulphuric acid is increased by internal or 
external use of phenol (carbolic acid), also in certain diseases as 
tuberculous enteritis, pyaemia, intestinal obstructions, etc. 

Carboluria is the name given to the voiding of dark 
urine, the result of excessive use of carbolic acid which splits up 
in the urine into pyrocatechin and hydroquinone, which sub- 
stances, on exposure to the air, become dark-brown in alkaline 
urine. 

Phenol has been found in the urine of patients taking guaiacol 
carbonate in large doses. 

Other conjugate sulphates: — Several other conjugate 
sulphates occur in urine: they are paracresol-sulphuric acid 
C7H7O.SO2.OH3 forming paracresol-potassium sulphate, pyro- 
catechin, and hydroquinone. Hydr< qu none is recognized by 
the development of a quinone-like odor, when heated with ferric 
chloride. 

16 



122 URINARY ANALYSIS. 



CHAPTEE XYII. 



NORMAL URINARY COLORING MATTERS AND 
CHROMOGENS. 

Urinary pigments are of two classes (a) those 
already formed and (b) those appearing only on addi- 
tion of certain reagents. 

Preformed coloring matters: — These are uro- 
chrome and uroerythrin. Urochrome is the substance 
to which the normal yellow color of urine is due to a 
certain extent. It is probably identical with the nor- 
mal urobilin of MacMunn, is derived from bilirubin, 
and results from oxidation of the latter in the intes- 
tinal tract. Bilirubin, as is known, has its origin in 
the haematin and haemoglobin of the blood. Uro- 
chrome may also originate directly from blood-pig- 
ments. It is increased in cases in which resorption of 
large extravasations of blood is taking place, i. e., 
whenever an increased destruction of red corpuscles is 
noted, and decreased in conditions associated with 
deficient formation of red corpuscles, as in anaemia, 
Bright's disease, diabetes, diseases of the bone mar- 
row, etc. It is closely related, chemically, to a color- 
ing matter known as urobilin, or better, pathological 
urobilin, from which, however, it may be readily 
distinguished by the spectroscope. [See Abnormal 
Coloring Matters and do not confound notes on "uro- 
bilinuria" in books and journals with the voiding of 
urine containing normal urobilin or urochrome. Much 
confusion exists in regard to these substances]. 

Urochrome or normal urobilin of MacMunn may be obtained 
from normal urine by acidulating with 1 to 2 grammes of dilute 
sulphuric acid for each liter of urine, filtering, and saturating 
with ammonium sulphate; the flakes which are found in an 
excess of the ammonium sulphate are dried, treated with warm, 
slightly am moniacal absolute alcohol, and the pigment obtained 
on evaporation of the alcohol. 



NORMAL URINARY PIGMENTS. 123 

An alcoholic solution of the pigment thus obtained 
exhibits a beautiful greenish fluorescence when treated 
with ammonia and a few drops of solution of zinc 
chloride, in this respect resembling pathological uro- 
bilin, but it differs from the latter spectroscopically 
in that its acidulated alcoholic solutions present a 
broad band of absorption at "F" extending more to 
the left than to the right of this line, while the 
remainder of the spectrum at the same time is ab- 
sorbed to the right end from a point somewhat to the 
left of "G." 

Uroerythrin is the pigment to which the red color 
of urate sediments and uric acid crystals is due. It is 
related chemically to haemoglobin, haematoidin, and 
bilirubin. When abundantly present in urine, it gives 
a salmon-red color to urinary sediments. Its quantity 
may be judged by the following test: Add solution 
of barium chloride or of neutral lead acetate to the 
urine and let the precipitate settle, waiting ten or fif- 
teen minutes; a milky-white precipitate indicates 
absence of uroerythrin, a pale rose-colored one pres- 
ence of uroerythrin in appreciable amounts, and a 
more pronounced rose-color large quantities. 

Uroerythrin is, when present in notable quantities, 
indicative of hepatic insufficiency, in which the liver, 
owing to a greatly increased destruction of red cor- 
puscles, is either unable to transform all the blood 
pigment carried to it into bile pigment or else an abso- 
lute insufficiency on part of the hepatic cells exists, so 
that the organ is not even able to bring about trans- 
formation of a normal quantity of haemoglobin. The 
diseases in which uroerythrin is found in large quan- 
tities in the urine are hepatic cirrhosis, carcinoma of 
the liver, pneumonia, malarial fever, erysipelas, spinal 
curvature, etc. 

According to recent writers normal urine contains two other 
pigments, namely urospectrin and hcematoporphyrin. Urospec- 
trin is extracted from urine by shaking the latter with acetic- 
ether which removes about two-ninths of the coloring matter. 
The residue left upon evaporation of the acetic-ether extract is 
soluble in ether. The ether extract contains the chromogen of 
urobilin and urospectrin. Upon exposure to light the urobilin 
chromogen is decomposed and the urobilin may be removed by 



124 URINARY ANALYSIS. 

shaking with water. Solutions of urospectrin in ether and alka- 
lies give four absorption bands; acid solutions give two bands. 

HaBmatoporphyrin may be extracted from urine by adding 
20 c.c. of a ten per cent solution of sodium hydroxide to every 
100 c.c. of urine; the precipitated phosphates are collected and 
washed with water. The precipitate is dissolved in rectified spirit 
and acidified with hydrochloric acid; the solution shows the bands 
of acid haematoporphyrin. Ammonia is then added to precipi- 
tate the phosphates and acetic acid to redissolve them; chloroform 
then extracts the pigment completely and shows the bands of the 
alkaline pigments. 

Normal chromogens: — Chromogens are substances 
which when treated with certain reagents yield 
pigments. The chromogens of normal urine are 
indican, urohasmatin, and an unknown chromogen 
which yields urorosein, when treated with mineral 
acids, hence called uroroseinogen. Indican has 
already been considered under the heading of conju- 
gate sulphates. Urohcematin appears to be the 
chromogen of the red pigment found in urine and 
called by various names, as the red pigment of Scherer, 
indigo-purpurin of Bayer, urrhodin of Heller, indigo- 
red, etc. It is probably an indoxyl derivative ; when 
present in increased amount, it is conveniently 
detected by the reaction of Rosenbach, as follows : 
Boil the urine and add to it, while boiling, nitric acid, 
drop by drop. In presence of large amounts of the 
red pigment the urine will assume a dark Burgundy 
color, which sometimes takes on a bluish tinge, if 
held to the light; the mixture becomes cloudy, and 
the foam assumes a blue color. In some cases addition 
of from 10-20 drops of acid will suddenly change the 
color from red to yellow, while in others the 
Burgundy color is not changed. 

Kosenbach's reaction is an important one and its 
significance is the same as the well-marked indican 
reaction, namely, greatly increased intestinal putrefac- 
tion, as in extensive disease of the small intestine, in 
carcinoma of the stomach, acute and chronic peri- 
tonitis. The reaction has been found to be absent in 
carcinoma of the colon, occlusion of the large intestine, 
stricture of the oesophagus, and chronic diarrhoea. 
If constant and continued in spite of medical or 



NORMAL URINARY PIGMENTS. 125 

surgical measures, Rosenbach's reaction is of bad 

prognostic significance. 

Uroroseinogen is the chromogen which yields a rose-red pig- 
ment, urorosein, apparently identical with Heller's urophain. It 
is not a conjugate sulphate, but otherwise little or nothing is 
known of its chemical nature. It occurs normally only in traces 
but appreciable amounts are found pathologically and may be 
detected as follows: — Treat 5 or 10 c.c. of urine with an equal 
amount of concentrated hydrochloric acid and 1 or 2 drops of a 
concentrated solution of bleaching powder. If much indican is 
present the mixture first assumes a dark greenish, blackish, or 
dark-blue color, owing to formation of indigo. When the mix- 
ture is shaken with chloroform, the supernatant fluid will exhibit 
a beautiful rose-color due to urorosein. This may then be ex- 
tracted with amyl alcohol, and separated from any other pigment 
present at the same time, by shaking with sodium hydrate, by 
means of which the solution is decolorized. On the addition of a 
drop or two of hydrochloric acid to the alcoholic extract the rose- 
color will reappear. 

A. rose-red ring due to this pigment may be noticed in patho- 
logical urines when Heller's cold nitric acid test is used for detec- 
tion of albumin. 

Appreciable amounts of this pigment are met with in patholog- 
ical conditions associated with grave disturbances of nutrition, 
as nephritis, diabetes, carcinoma of the stomach and dilatation, 
pernicious aniemia, typhoid fever, phthisis, and at times in pro- 
found chlorosis. It is also apparently increased by vegetable diet. 



CHEMICAL EXERCISE VU. 

The student having collected his twenty-four hours' 
urine should test it for the following ; 

1. Indican: — Chapter XVI, Stokvis-Jaffe test. 

2. Skatoxyl: — Chapter XYI, Jaffe's test. 

3. Obtain urochrome by the process outlined in 
chapter XVII. 

•±. Test for uroerythrin with neutral lead acetate 
solution : Chapter XVII. 

5. Try Rosenbach' ] s reaction: Chapter XVII. 

6. Test for urorosein: Chapter XVII. 

7. Compare the Stokvis-Jaffe test for indican with 
Richardson' 's- test, as follows : Take equal quantities 
of urine and hydrochloric acid, add a few drops of 
a solution of hydrogen dioxide, and then chloroform 
as in Jaffe's test. 



126 URINARY ANALYSIS. 



CHAPTEE XVIII. 



THE NON-NITROGENOUS ORGANIC ACIDS OF NORMAL 

URINE. 

The non-nitrogenous organic acids occurring 
normally in urine may be classified as follows : 

1. Oxalic acid combined with calcium forming 
calcium oxalate. 

2. Succinic and lactic acids. 

3. Acids of the fatty acid group: Formic, acetic, 
butyric, propionic. 

4. Glycero-phosphoric acid. 

Oxalic acid:— In combination forming calcium oxalate CaC 2 4 
held in solution by the sodium dihydric phosphate of the urine. 

Sediments therefore contain calcium oxalate when the urine is 
diminished in acidity or on standing exposed to the air. The 
occurrence of calcium oxalate in the sediment does not then 
necessarily indicate excess of it in the urine. For the quantitative 
determination of the oxalic acid in urine no simple process is 
known. See Appendix for complete process, and Sediments for 
other information, pathology, etc. 

Oxalic acid is related to uric acid as is also another acid found 
in normal urine known as oxaluric acid, which occurs in traces 
in the urine as ammonium oxalurate. 

Succinic acid has occasionally been found in urine after 
ingestion of asparagus and asparagin. It is a third acid of the 
oxalic series The relationship of the acids of the oxalic series 
may be seen by the formulas, as follows: 

Oxalic acid, H 2 Co0 4 or COOH.COOH. 

Oxaluric acid, (CONoK 8 ).CO COOH. 

Succinic acid, COOH.C 8 H 4 .COOH. 

Lactic acid probably does not occur in urine, but sarco-lactic is 
said to occur after severe muscular labor and physiological dis- 
turbances. It is, however, chiefly met with in pathologic states 
and should be considered among the constituents of abnormal 
urine. There are no tests for it available for clinical purposes. 
It has been found in trichinosis, acute yellow atrophy of the liver, 
phosphorus poisoning, rickets, leukasmia, osteomalacia, cirrhosis 
of the liver. 

The Fatty acids occur in traces under normal conditions and 
are probably formed in the lower segment of the small intestine. 
They are formic, acetic, butyric, and propionic, and occur appar- 
ently in the free state. They are increased slightly in (a) febrile 
disorders and greatly in (6) hepatic diseases affecting the structure 



NORMAL ORGANIC ACIDS. 127 

proper of the liver; they are also increased (c) in diabetes. The 
condition when they are present in increased amount is known as 
lipaciduria. 

There is no simple method of detection; the usual method of 
detection is to distill the urine with phosphoric acid, neutralize 
the distillate carefully with sodium carbonate, evaporate to dry- 
ness on the water bath, extract the residue with boiling alcohol, 
filter, evaporate again, dissolve in water, and test as follows: — 

1. Treat solution with sulphuric acid and alcohol. Odor of 
acetic ether shows presence of acetic acid. 

2. To another portion add ferric chloride solution: a red tint 
appears which disappears on boiling leaving a rusty precipitate. 

3. Addition of silver nitrate solution causes a white precipitate 
which rapidly blackens it formic acid is present. 

Glycero-phosphoric acid, C 3 HsP0 6 , occurs in small traces in 
normal urine, resulting as a decomposition product of lecithin, 
which is a combination of choline and glycero-phosphoric acid, 
occurring in the bile, brain, yolk of egg, etc. 

The normal quantity of glycero-phosphoric acid in urine is said 
to be about 15 milligrams per liter. It is increased in chyluria. 
pernicious anaemia, dementia, lesions of the brain substance, 
diabetes mellitus, and after chloroform narcosis. 

Inasmuch as in the writer's experience the phosphoric acid of 
the urine (oxidized phosphorus) is certainly diminished in condi- 
tions of nerve waste, it is reasonable to suppose that the glycero- 
phosphoric acid (unoxidized phosphorus) is increased at the same 
time. The experience of Robin would appear to confirm this 
view, hence the use clinically of the glycerophosphates, phospho- 
albumins, etc. 

Unfortunately it is a difficult matter to determine the glycero- 
phosphoric acid in urine hence see Appendix for processes. 



128 URINARY ANALYSIS. 



CHAPTEE XIX. 



CARBOHYDRATES NORMALLY PRESENT IN URINE 

The carbohydrates normally present in urine may 
be classified as follows : 
I. Glucose. 
II. G-lucosazone. 

III. A substance allied to dextrine. 

IV. A carbohydrate in combination with benzoyl. 
V. Animal gum. 

VI. Inosite. 
VII. Lactose. 

The total amount of carbohydrates with reducing properties 
eliminated daily in normal uriue, has been shown by Baisch to be 
from 0.12 to 0.32 gm. (about 2 to 5 grains), of which glucose itself 
amounts to from 0.08 to 0.18 gm. or about 1J to 2$ grains. 
Among the other carbohydrates are glucosazone, a substance 
allied to dextrine, and a carbohydrate in combination with 
benzoyl. 

Animal gum is a mucin product. It is precipitated by alcohol 
but does not reduce alkaline solutions of cupric salts. 

Inosite, a sugar found in small quantities in normal urine, 
CeHaaOe.SHaO, muscle-sugar. It is usually found in normal 
urine only after use of large quantities of water. 

Form:— Crystalline, when obtained pure, forming large, fine, 
clinorhombic or monoclinic tables. Impure it crystallizes in 
cauliflower-like masses. 

Solubility: — Soluble in 16 parts water at 10° C, insoluble in 
absolute alcohol and ether. 

Properties: — Sweetish taste, does not rotate plane of polariza- 
tion, does not ferment. In alkaline solution it does not reduce 
hydrated cupric oxide. It yields sarco-lactic acid when 
fermented with putrefying albumin. 

Tests: (1) Scherer's test: — On evaporating a solution contain- 
ing inosit on the water bath nearly to dryness in a porcelain dish, 
having added a few drops of common nitric acid, and then treat- 
ing the nearly dry residue with some drops of a freshly-prepared, 
not too dilute, watery solution of ammonia and calcium chloride 
solution, a rose-red mass remains, which, after some time, 
becomes changed in color. 

(2) Gallois's test: — An aqueous solution treated in a porcelain 
dish with a little mercuric nitrate Hg (N0 3 ) 2 in solution—a drop 
will suffice — gives a yellowish precipitate. If this is spread out 
on the edge of the dish quickly, and heated carefully, it becomes 



NORMAL CARBOHYDRATES IN URINE. 129 

dark red. The color disappears on cooling to reappear on heat- 
ing. Albumin, sugar, and tyrosin interfere with the reaction. 

Preparation from urine:— A large quantity of urine (several 
liters) is feebly acidified, precipitated completely with neutral 
acetate of lead, filtered, and the warmed filtrate treated with 
basic acetate of lead, as long as a precipitate forms. After stand- 
ing for forty-eight hours this precipitate is filtered off, washed, 
suspended in water, and treated with a stream of sulphuretted 
hydrogen. From the filtrate, after some hours, uric acid sepa- 
rates, from which the fluid is poured off. The solution is then 
evaporated to a syrup on the water bath, and precipitated with 
absolute alcohol. " The precipitate is dissolved in hot water and 
three or four times as much alcohol of 90 per cent as water 
added. The alcohol is then treated with ether until the clouding 
is permanent, when the inosit crystallizes out. The watery 
solution can be used for Scherer's reaction directly (Salkowski 
and Leube). 

Pathology: — Inosite is found in the urine in increased 

quantity in diabetes, mellitus and insipidus; also in 

Brigkt's disease. 

Lactose, milk-sugar, an organic substance, carbohydrate 
C12H22O11.H2O, is found in the urine of nursing-mothers and in 
lesions of the mammary glands. Positive detection of it is diffi- 
cult because of its resemblance to glucose in answering to tests. 
The writer has found, however, that it reduces Haines's test- 
liquid more slowly than glucose. (See writer's Chemistry, 4th 
edition, p. 525.) Its presence may be inferred if a positive result 
is obtained with Trommer's and Nylander's tests for glucose (see 
Chap, on Sugar), while the phenylhydrazin and fermentation tests 
give negative results. It is said that persistent and copious elim- 
ination of lactose in the urine is a sign of a good wet-nurse. 
The most certain means for its detection is to isolate it according 
to the method of F. Hofmeister. Precipitate the urine with 
sugar of lead, filter, wash with water, unite the filtrate and wash- 
water, and precipitate with ammonia. The liquid filtered from 
the precipitate is again precipitated by sugar of lead and ammo- 
nia, until the last filtrate is optically inactive. The several pre- 
cipitates, with the exception of the first, which contains no sugar, 
are united and washed with water. The washed precipitate is 
decomposed in the cold with sulphuretted hydrogen and filtered. 
The excess of sulphuretted hydrogen is dri\ en off by a current of 
air; the acids set free are removed by shaking with silver oxide. 
Now filter, remove the dissolved silver by sulphuretted hydrogen, 
treat with barium carbonate to unite with any free acetic acid 
present, and concentrate. Before the evaporated residue is 
syrupy it is treated with 90 per cent alcohol until a flocculent 
precipitate is formed, which settles quickly. The filtrate from 
this when placed in a desiccator deposits crystals of milk-sugar, 
which are purified by re-crystallization, decolorizing with animal 
charcoal and boiling with 60-70 per cent alcohol. 

1? 



130 URINARY ANALYSIS. 

THE MUCOUS CLOUD (NUBECULA) IN URINE. ENZYMES. PTOMAINES 

Normal urine, on standing, deposits a slight cloud 
in the case of men, but a bulky one in the case of 
women. If this "cloud" be removed by means of a 
pipette and sedimented in the centrifuge the micro- 
scope shows it to consist of a few mucous corpuscles 
and pavement epithelia in the case of men, but in 
women a great mass of epithelia may be seen, of 
vaginal origin. Traces only of mucin or a mucin-like 
substance or even none at all are to be found in the 
urine of healthy men, while in women admixture of 
vaginal fluids causes a mucin-reaction in almost every 
sample of urine examined. See Mucinuria in Chap- 
ter on "Albumin." 

The enzymes found in urine are the following: 

Diastase:— Minute quantities of ptyalin or a similar diastatic 
ferment have been obtained from urine. 

Pepsin, an organic ferment, has been isolated from normal 
urine and is found most abundant in the morning. Small pieces 
of fibrin soaked in urine absorb the pepsin from it and, on being 
removed to 0.1 per cent hydrochloric acid solution, they are then 
rapidly digested. 

Rennet:— Traces of a ferment which curdles milk have been 
found in urine. 

Ptomaines: — These organic substances, and leucomaines, 
poisonous substances of an unknown kind, which are often called 
alkaloidal substances, occur in normal urine according to Bou- 
chard and others. (See Toxicity of Urine.) 



INORGANIC CONSTITUENTS OF URINE. 131 



CHAPTER XX. 



INORGANIC NORMAL CONSTITUENTS OF URINE. 

The inorganic normal constituents of urine will be 
considered under the following 
Classification. 

I. Compounds of the negative elements phosphorus, 
chlorine, and sulphur, forming phosphates^ chlorides, 
and sulphates, occurring in considerable quantity in 
the urine. 

II. Compounds of other elements occurring in small 
quantity or in traces in the urine — nitrates, nitrites, 
carbonates. 

III. Free gases. 

THE PHOSPHATES, 

Introductory: — Phosphoric acid, H 3 P0 4 , occurs in 
the urine entirely in combination with bases, forming 
phosphates. 

There are several kinds of phosphates in urine, and 
this is why the beginner meets with difficulty. Let it 
be remembered, first, that all urine normally contains 
phosphates dissolved in it, and, second, that under 
certain circumstances some of these phosphates appear 
in the urinary sediment. But all the phosphates in 
urine are not found in the sediment under any circum- 
stances. The phosphates which are always in solution 
and never in the sediment are the phosphates of sodium 
and potassium, and are called alkaline phosphates. 
The phosphates which are sometimes in solution and 
sometimes in the sediment are the phosphates of cal- 
cium and magnesium, the so-called earthy p>hosphates. 

The question now arises, When does the urine con- 
tain phosphates in the sediment? The answer is, 
when the reaction is feebly acid, neutral, or alkaline. 
The phosphates of calcium and .magnesium are dis- 



132 URINARY ANALYSIS. 

solved by acid urine, but when the urine, for any 
reason, loses its acidity these phosphates separate, and 
form a dirty-white flocculent sediment, The other 
phosphates, those of sodium and potassium, however, 
are not affected by any change in the reaction, but 
remain always in solution. We have, then, the 
following : — 

Acid urine: — Phosphates of sodium and potassium 
in solution, H 3 NaP0 4 and H KP0 4 . Phosphates of 
calcium and magnesium, in solution, Ca.^PCM' and 
MgHP0 4 .7H 2 0. 

Alkaline urine: — Phosphates of sodium and potas- 
sium in solution. Phosphates of calcium and mag- 
nesium in the sediment. 

Ammoniacal urine: — Same as alkaline urine plus 
triple phosphate, NH 4 MgP0 4 . 6H 2 (ammonio-mag- 
nesium phosphate), in the sediment. 

I hope that this table makes matters sufficiently 
clear. Nearly every year my students are disconcerted 
by the fact that the alkaline phosphates do not appear 
in the sediment, whilst the earthy phosphates may. 

Solubility: — When feebly acid or alkaline urine is 
boiled, it becomes cloudy from precipitation of phos- 
phates. These phosphates thus precipitated are 
always the earthy phosphates, those of calcium and 
magnesium, never the alkaline phosphates, those of 
sodium and potassium. The alkaline phosphates are 
always in solution in the urine, whether it be acid or 
alkaline in reaction, or hot or cold in temperature. 

JSTow, inasmuch as albumin, if present in the urine, 
is coagulated by boiling, the earthy phosphates, when 
urine is feebly acid or alkaline, may be, and, to my 
knowledge, frequently are, mistaken for albumin. 
Addition of acetic acid, however, dissolves the phos- 
phatic cloud but does not affect the albuminous 
coagulum, if such it be. So then, not only do the 
earthy phosphates form a sediment or deposit in 
alkaline urine, but if either feebly acid or alkaline 
urine is boiled, they are thrown out of solution. In 
other words, the phosphates of calcium and mag- 
nesium possess the remarkable property of being less 



PHOSPHATES. 133 

soluble in hot than in cold water. The alkaline phos- 
phates, those of sodium and potassium, are not affected 
by boiling the urine, and cause no trouble. 

Again, when urine is tested for sugar, either by 
liquor potassae, by Haines' liquid, Trommer's or 
Fehling's test, a complication ensues from presence 
of phosphates. Inasmuch as these tests all involve 
addition of strong alkalies to the urine, and boiling, it 
follows, from what is said above, that the earthy 
phosphates will be precipitated whether or not sugar 
is present. Hence, when sugar is absent, a dirty 
white precipitate of earthy phosphates will always be 
seen, sometimes more conspicuous, sometimes less. 
Whenever urine is boiled loith an alkali or with a blue 
sugar-test liquid (which contains alkali) flocks of 
precipitated earthy phosphates will be seen. These 
phosphates are the phosphates of calcium and mag- 
nesium, not of potassium and sodium. We have then 
the following : 

Summary: — Phosphoric acid, H 3 P0 4 , combined 
with bases, is found in all urine, forming phosphates. 

1. Alkaline phosphates: — Phosphates of sodium and 
potassium, present in solution in every sample of urine, 
never in the sediment, not affected by boiling, nor by 
addition of alkali. Do not complicate the albumin 
tests nor the sugar tests. 

2. Earthy phosphates: — Phosphates of calcium and 
magnesium. Present in solution in every sample of 
urine and also in the sediment of every alkaline urine. 
Precipitated from solution in feebly acid, neutral, or 
alkaline urine when the latter is boiled. Precipitated 
whenever an alkali like liquor potassae is added to the 
urine, as in the various tests for sugar. Re-dissolved 
when any acid is added to the precipitate, or to the 
sediment. 

The composition of the phosphates may vary some- 
what with the reaction of the urine. Thus in acid 
urine we may have acid phosphates, JSTaH.PO, and 
Cali^PC^).- ; in neutral urine, neutral phosphates, 
Ka 2 IlP0 4 ,CaHP0 4 ,MgHP0 4 ; in alkaline urine, basic 
phosphates i^a^PC^, etc. 



134 URINARY ANALYSIS. 

3. Triple phosphate: — In addition to the phos- 
phates already mentioned there is still another phos- 
phate, known as ammonio-magnesium phosphate, or 
"triple" phosphate. (It is called triple phosphate, 
]STH 4 Mg.POj.6II_0, because of the water of crystal- 
lization forming the third part of its formula.) This 
phosphate is naturally not found in normal urine but, 
if for any reason, through disease (septic inflammation 
of the urinary passage), retention of urine takes place, 
either in the kidney-pelvis or in the bladder, and there 
is decomposition of urea, ammonium carbonate being 
formed, some of the ammonium unites with the mag- 
nesium phosphate of the urine to form the double salt, 
ammonio-magnesium phosphate, which, however, 
owing to the presence of six molecules of water in its 
formula, has received the name of "triple" rather 
than "double." So, then, triple phosphate is found 
in the sediment of amino niacal urine. It is also some- 
times found in slightly acid urine (acidity probably 
due to some salt which reddens litmus) and in alkaline 
urine without odor of ammonia. 

Urine which turns red litmus paper permanently 
blue is said to be alkaline from fixed alkali (carbonates 
of sodium and potassium). Urine which turns red 
litmus paper blue, the latter fading on exposure to air, 
and which has odor of ammonia, is said to be alkaline 
from volatile alkali. It is in urine alkaline from vola- 
tile alkali that we find the triple phosphate. Such 
urine is always, when freshly voided, significant of dis- 
ease. Care must be taken to note the words 'when 
freshly voided." 

Chemical tests: — From what has already been said 
it is easy to see that a simple test for earthy phos- 
phates is to add to any sample of urine sufficient liquor 
potassse to render it alkaline, and then boil. Flocks 
of phosphates at once appear. They are usually dirty 
white, but may be reddish or brownish. To detect 
the alkaline phosphates, filter the sample and add to 
the clear filtered urine one-third its bulk of magnesian 
fluid, when a snow-white deposit takes place. 



PHOSPHATES. 135 

Magnesian fluid is made by dissolving 10 grams (155 
grains) of pure magnesium sulphate and a like amount 
of pure ammonium chloride in 10 c.c. of strong aqua 
ammoniae and 80 c.c. of distilled water. 

How may the quantity of phosphates in the urine 
be determined? Accurate analyses are made with 
difficulty for the general practitioner, so that the 
volumetric determination of the total phosphoric acid 
is the best method to be followed. It is given in 
Chemical Exercise (?). 

physiology of the phosphates. 

Quantity: — Different observers make from 2 to 4 
grams of phosphoric acid normal per twenty-four 
hours. The author inclines to the opinion that for 
Americans 2 to 2.5 grams (31 to 38 grains), is not too 
small.* Of this quantity about one- third is bound to 
the earthy phosphates, and two-thirds to the alkaline. 
The total quantity of phosphates is variously reckoned 
at from 3 to 5.5 grams per twenty-four hours (45 to 
85 grains). Of this the earthy phosphates form 1 to 
1.5 grams (15 to 22 grains), and the alkaline 2 to 
4 grams (30 to 60 grains). These figures are 
altogether to high in case of Americans, so far as my 
experience goes. The proportion of calcium phos- 
phate to magnesium phosphate is given by Tyson as 
33 to 67. The potassium phosphate is the smallest in 
amount of all the phosphates. 

Source: — Phosphoric acid in the urine comes largely 
from the blood, but also partly from the decom- 
position of lecithin (a phosphorized fatty body, 
C 4 >H 84 KP0 9 , occurring in brain and nerve tissue), 
and nuclein (an albuminoid substance occurring 
in the nuclei of corpuscles, in spermatozoids, brain, 
milk, etc.), which also contains phosphorus. 
Nerve tissue yields relatively more phosphorus 
than muscle tissue. 

Formation: — In the blood phosphoric acid is found 
combined with bases forming phosphates: neutral 

*Ten medical students in health, whose urine was examined by 
the writer, averaged 2 grams (31 grains). 



136 URINARY ANALYSIS. 

sodium and neutral potassium phosphates in the blood 
appear in the urine as acid salts, for the reason that 
by the act of secretion the bicarbonates and neutral 
phosphates in the blood become carbonates and acid 
phosphates, according to the equation : 

HNaCO, + HNa 2 P0 4 = Na 2 C0 8 + H 2 NaP0 4 

sodiam central sodium sodium 

bicarbonate, sodium carbonate, acid 

phosphate, phosphate. 

The acid salts pass out in the urine, obeying the law 
of diffusion, but the carbonates remain in the blood. 

Excretion: — The maximum excretion is in the even- 
ing, the minimum about mid-day. The excretion 
varies somewhat with the amount of food taken, being 
increased by meat diet, since this tends to increase 
formation of alkaline phosphates. According to Dr. 
Long the phosphates in urine have decreased since 
changes in milling processes have made material reduc- 
tions in the percentage of phosphates in flour. Phos- 
phatic beverages are said to increase the phosphates in 
the urine, but in the writer's experience no great ex- 
cess has been found in any considerable number of 
cases from any cause whatever, the general tendency 
being toward figures considerably lower than those of 
the European observers. The phosphates are said to 
be increased by drinking freely, but increased elimina- 
tion is followed by a certain degree of retention. 

Ratio of urea to phosphoric acid in health: — 
Like all other ratios this is given differently by differ- 
ent observers. From 8 to 1 to 10 to 1 is adopted by 
some. E. E. Smith thinks it to vary between 12 and 
15 to 1. In my own experience out of 36 cases 
recently examined in which this ratio was determined, 
in persons in whose urine no abnormal constituents 
could be found, and who were, so far as I know, 
healthy, the following was the result : 

Ratios less than 10 to 1 9, 

10 to 1_. 3, 

11 to 1 10, 

12 to 1 5, 

13 to 1.... 3, 

14tol_ 4, 

16 to l._ 2. 



INORGANIC CONSTITUENTS OF URINE. 137 

In other words, $7 out of 36 were not over 1% to i, 
so that ratios above 12 to 1 must be regarded as infre- 
quent. I incline to the opinion that the ratio varies 
between 8 to 1 and 12 to 1, when the clinical urea 
instruments are used. 

It must be borne in mind, however, that the clinical process for 
determining urea is not accurate, chemically speaking, while the 
volumetric determination of P 2 B by uranium nitrate is in most 
cases accurate. In all research work the ratio of total nitrogen 
to phosphoric acid is to be preferred. See Appendix for Kjel- 
dahl-Gunning method. 

CHEMICAL EXERCISE VIII. 

DETECTION AND ESTIMATION OF PHOSPHATES IN THE URINE. 

The presence of phosphates in the urine is ver v y 
readily shown by means of certain simple tests'. 
Moreover in testing for albumin and for sugar these 
substances are often precipitated since all urine con- 
tains them in greater or less amount. 

A. Detection of earthy phosphates: — To half a test 
tube full of urine add a few drops of ammonia or 
other alkaline solution, shake well, and boil; whitish 
flocks appear, indicating presence of earthy phosphates. 
Tf blood is present, the flocks are blood red ; if bile, 
yellow-brown; if vegetable colors (as rhubarb, senna) 
rosy -red. 

B. Detection of alkaline phosphates: — Filter the 
mixture obtained in A and to the filtrate add one-third 
its volume of magnesian fluid. A snow-white pre- 
cipitate, crystalline ammonio - magnesium phosphate, 
mixed with amorphous calcium phosphate, occurs. 
(The crystals thus rapidly formed have a fern-leaf 
shape (Fig. 31), not prismatic, nor coffin-lid, as in spon- 
taneous deposits. See Sediments). 

Note:— The student should bear in mind the difference in 
results obtained by tests A and B, and understand the reason for 
it. The earthy phosphates in test A are actually seen, being 
thrown out of solution on addition of alkali. The alkaline phos- 
phates (of sodium and potassium) on the other hand do not thus 
appear in test B. Owing to the ready solubility in water of com- 
pounds of sodium and potassium, it is difficult to precipitate them 
unchanged from solution. We must have recourse to another 
method, i. e., that of splitting them up by double decomposition 
18 



133 URINARY ANALYSIS. 

as it is termed and obtaining a precipitate of a new and insoluble 
compound. The phosphates of sodium and potassium are split 
up by the magnesian fluid, the phosphate radical uniting with 
the ammonium and magnesium to form a new and insoluble 
compound, ammonio-magnesium phosphate. By insoluble 
understand in the fluids used. 

C. Precipitation of phosphates by heat: — Obtain 
some urine which is feebly-acid, as after a hearty meal 
or at time of "alkaline . tide" (10:30 a. m.), filter 
clear, through three thicknesses of filter paper, into a 
tall, narrow test-tube. Fill it about three-quarters 
full. Hold tube by closed end between thumb and fore 
finger, and boil upper third of the liquid over a spirit 
lamp. A cloud appears owing to precipitation of 
earthy phosphates. Add ten drops of 20 per cent 
acetic acid, and shake; the cloud disappears, the 
phosphates being dissolved by the acid. 

D. Approximate determination of earthy phosphates: — A test- 
tube, 16 centimeters (6.2992 inches) long and 2 centimeters (.787 
inch) wide, is filled one-third with clear or Altered uriue, to which 
a few drops of caustic ammonia or caustic potash solution are 
added, and warmed gently over a spirit lamp until the earthy 
phosphates begin to separate in flakes. It is then placed aside 
for ten or fifteen minutes for them to subside. If the layer of 
sediment is one centimeter (.3937 inch) high, the earthy phos- 
phates are present in normal amount; if they occupy two to three 
centimeters (.787 to 1.181 inch), they are increased; if, on the 
other hand, only a few flakes are visible, the earthy phosphates 
are diminished. 

E. Approximate determination of alkaline phosphates: — To a 
suitable quantity of urine placed in a beaker-glass about one-third 
as much of the magnesian fluid is added. All of the phosphates 
are thrown down in the shape of a snow-white deposit. If the 
entire fluid present a milk like cloudy appearance, the alkaline 
phosphates may be considered present in normal amount; if it is 
denser, more cream-like, there is an increase. If, on the other 
hand, the fluid is but slightly cloudy, transmitting light distinctly, 
the phosphates are diminished.* 

APPARATUS REQUIRED. 

Test-tube rack and t^st-tubes. 

Bunsen burners or alcohol lamps. 

Aqua ammonias or liquor potassse. 

Funnels and filters. 

Magnesian fluid. 

Test-tubes, 6J inches long and f-inch in diameter. 



* In the writer's teaching experiei oe, students cannot, be depended on to 
decide by this test whether the phosphates are normal or increased. 
Whenever possible the volumetric det rmmation of phosphoric acid should 
be made. 



INORGANIC CONSTITUENTS OF URINE. 



139 



MICROSCOPICAL EXERCISE. 

A. Let the precipitate of earthy phosphates settle, 
or obtain some already deposited in urine, and exam- 
ine a drop of the sediment with both low and high 
power (150 and 500 diameters). Note that the sedi- 
ment is amorphous, and consists of minute, pale gran- 
ules in irregular patches. (See Sediments of Phos- 
phates for figures). 

B. Let the precipitate with magnesian fluid settle, 
and examine a drop. In addition to the granular 
patches will be seen amongst others the so-called 
"fern-leaf'' crystals of triple phosphate which is the 




Fig. 33. Fern-leaf crystals of triple phosphate. 

form the latter assumes when rapidly developed. 
(See Sediments of Phosphates for figures). No "cof- 
fin-lid" crystals are seen, but several other forms. 



140 URINARY ANALYSIS. 



CHAPTEE XXI. 



PATHOLOGY AND CLINICAL SIGNIFICANCE OF THE 
PHOSPHATES IN URINE. 



After making several thousand volumetric deter- 
minations of phosphoric acid in the 24 hours' urine 
the writer has come to the conclusion that decrease of 
phosphoric acid is far more common in disease than 
increase. In fact decrease of phosphoric acid is one 
of the commonest accompaniments of disease. 

A. Diseases in which the total* phosphates may be 
increased in the urine: 

1. Some cases of diabetes mellitus. 

2. In the condition known as phosphatic diabetes 
(Tessier, Ralfe, and others). 

3. Earthy phosphates increased in diffuse diseases 
of the bones, and in diffuse periostitis ; in diseases of 
the nerve centers. 

According to Zuelzer and others, phosphoric acid is 
also increased in : 

4. Convalescence from febrile diseases. 

5. Epileptic attacks. 

6. Small-pox. 

7. Cerebro-spinal meningitis. 

8. Cholera infantum. 

9. Leukaemia, just before death. 

10. Pseudo-leukaemia. 

According to Robin an increased elimination of 
phosphoric acid during the fastigium of typhoid fever 
is an unfavorable omen, while a decrease during defer- 
vescence is favorable. 

EXAMPLES PROM THE WRITER'S CASES. 

In 25 cases of diabetes mellitus with polyuria, the greatest 
amount of phosphoric acid found in 24 hours' urine was 5.8 gm. 
(90 grains). From 4 to 5 gm. were voided by four patients, and 

* The 24 hours' quantity is meant. 



PHOSPHATES IN URINE. 141 

from 3 to 4 grams by ten patients. Nineteen patients voided 
at one time or other from 3 grams down. In 18 collections of 
24 hours' urine of diabetics the quantity of phosphoric acid 
exceeded 3 grams, and in 32 collections it fell below that. So 
that not even in diabetes mellitus is excess of phosphates in 24 
hours more common than deficiency, taking 3 grams (46 grains) 
as average normal. 

The highest relative excretion was 2.25 gm. per liter, about one 
grain per ounce. It is said that in diabetes mellitus the quantity 
of P 2 6 rises and falls in inverse ratio to that of sugar. 

JB. Diseases in which phosjjhoric acid is especially 
deficient* 

1. Chronic Bright'' s disease, especially the inter- 
stitial form. 

2. Addison's disease. 

3. Many nervous diseases. 

4. Pyuria. 

5. Exophthalmic goitre. 

6. Tuberculosis. 

7. Cancer. 

8. Diseases of the uterus. 

According to Zuelzer, phosphoric acid is also dimin- 
ished in : 

9. Acute infectious diseases. 

10. In pneumonia, typhus, scarlet fever, paroxysms 
of intermittent fever, febrile phthisis. 

11. Acute nephritis. 

12 Arthritis, acute and chronic articular rheuma- 
tism, osteomalacia. 

13. Chronic anaemia. 

14. Chronic diseases of the brain and chronic 
mania. 

15. Hysterical attacks, in proportion to the intensity. 

16. Chronic lead poisoning. 

IT. Acute } T ellow atrophy of liver (absence possible). 

18. Cirrhosis of liver. 

Zuelzer mentions decrease of phosphoric acid in 
Addison's disease, in which the writer also has noted 
marked decrease. 

In some of these diseases the phosphates set free 
may possibly be utilized in the building up of new 
leucocvtes, hence the deficiency in the urine. 



* According to the writer's experience. 



143 URINAR Y ANAL YSIS. 

Ratio of nitrogen to phosphoric acid: — According to 
Zuelzer, the ratio of nitrogen to phosphoric acid in 
normal urine is 5 to 1. He finds this ratio increased 
wherever there is notable elimination of pus corpuscles 
through other channels ; in febrile diseases during the 
febrile period (pneumonia especially), in rachitis, 
anaemia, in all conditions of excitation of the brain, 
in diabetes mellitus, in scurvy, empyema, and in 
Addison's disease. The ratio is diminished in re-con- 
valescence from febrile diseases, in all conditions of 
depression of the brain, in tumors of the brain, in 
meningitis, tabes, myositis ossificans, arthritis de- 
formans, and progressive pernicious anaemia. 

Note: — The term "relative phosphoric acid" is used by the 
Germans to indicate the ratio of nitrogen to phosphoric acid. 
Thus Zuelzer says the "relative phosphoric acid" is diminished 
when the proportion of nitrogen to phosphoric acid is increased 
above 5 to 1. This term must not be confused with phosphoric 
acid relative to water (grams per liter, grains per ounce), as 
used by the writer. The term relative value of phosphoric acid 
is used by some writers to indicate the relation which exists 
between the elimination of nitrogen and phosphoric acid. This 
value supposes the absolute amount or value of phosphoric acid 
to vary between 2 and 3 grams a day, and is found according 
to the following: 

N : P 3 0, = 100 : x, and x = in" p .o 

N 
In which N indicates the amount of nitrogen actually observed, 
P 2 6 the amount of phosphoric acid in the same urine, and x the 
amount of phosphoric acid corresponding to 100 gin. of N. Nor- 
mally the relative value of P 2 6 in urine is from 17 to 20, an 
increase in this value has been noted in apoplexy (as high as 34.3), 
brain-tumors, tabes, arthritis deformans (30), pernicious anaemia 
(23.8 to 28). The value is decreased in anaemia, cerebral excita- 
tions, and especially preceding an attack of epilepsy, in chronic 
cerebral affections, delirium tremens, and acute hydrocephalus. 
In progressive paralysis following syphilis the value is low. but 
rises greatly after administration of potassium iodide. In the 
excitement of mania the value decreases; in the stage of depres- 
sion and in melancholia the alkaline phosphates are diminished 
and the earthy increased. 

The method of determining the total nitrogen of 
the urine is not ready enough for clinical purposes and 
is hence described in the Appendix. For ordinary 
clinical purposes we consider the ratio of urea to phos- 
phoric acid. 

The ratio of urea to phosphoric acid: — The ratio of 
urea (determined by the clinical instruments) to phos- 



PHOSPHATES IN URINE. 143 

phoric acid is likely to be specially increased (above 
14: to 1) in the following diseases in Americans: 

1. Pyuria. 

2. Chronic interstitial nephritis. 

3. Addison's disease. 

It is not likely to be greatly increased in cases of 
Bright' s with dropsy and abundantly albuminous 
urine. 

Zuelzer finds the ratio of nitrogen to phosphoric 
acid increased in diabetes meilitus. So far as the 
writer's experience goes in 25 cases recently examined, 
the ratio of urea (determined by clinical instruments) 
to phosphoric acid was as follows: Less than 10 to 1 
in 7 cases; 10 to 1 in 8 cases; 12 to 1 to 14 to 1, 
inclusive, in 7 cases (of which 3 were 12 to 1, 2 13 to 
1, 2 14 to 1); 16 to 1 in 3 cases. 

EXAMPLES FROM THE WRITER'S CASES. 

Bright" s Disease: — 

1. In the majority of 53 fatal cases of Bright's* disease the total 
quantity of phosphoric acid per 24 hours was found to be less than 
23 grains (1.5 grammes). 

2. The average for the whole of the fatal cases was only 18 
grains (1.14 grammes) in 24 hoars. 

3 Less than 15 grains (1 gram) was found in about 33 per cent 
of the cioalyses. 

4. More than 23 grains (1.5 gm.) occurred in about 33 per cent 
of the cases. 

5. More than 30 grains (2 gm.) occurred in only about 12 per 
cent. 

6. In no cases were more than 35 grains (2.2 gm.) found. 

7. Phosphoric acid seems to be decreased compared with urea 
in cases where pus is abundant in the urine. 

8. Phosphoric acid seems, as a rule, not to be decreased more 
than urea in cases where albumin is abundant in the urine. 

9. Phosphoric acid is sometimes decreased far more than urea 
in cases in which but little albumin is found. 

In Bright's disease there seems to be an actual insufficiency on 
the part of the kidneys in the elimination of phosphates. 

In the case of 67 patients, in whose urine albumin together with 
numerous granular, fatty, or waxy casts were found, and who are 
still living, the excretion of phosphoric acid was as follows: 

The majority of patients voided 1 to 2 gm, in 24 hours or 15 to 
30 grains; seventeen voided more and five less. The greatest 
quantity voided was 5.94 gm. (90 grains) and the least 0.3 gm. 
(about 5 grains). The average excretion was 1.8 gm., 28 grains 

The comparison between the excretion of phosphoric acid by 
those who died and by those who lived may be made as follows: 

* Granular, fatty, or waxy casts in the urine of all thesa patients, together 
with albumin. 



144 URINARY ANALYSIS. 

THE DEAD. THE LI VIVO. 

Above 2 gm 13 per cent of the patients.. 24 per cent. 

Above 1.5 gm... 34 " " " .. 57 

Above 1.0 gm 71 " " " .. 88 

Below 1.0 gm 31 " " " .. 10 " 

Greatest quantity per 

24 hours.. 2.2 gm. •. 5.94 gm. 

Average excretion... 1.14 gm 1.8 gm. 

In other words the percentage of those who passed more than 
1 gm. (15 grains) in 24 hours of both the living and the dead is not 
so very unlike, namely, 71 per cent of the dead and 88 per cent of 
the living, the excretion being nevertheless in favor of the living; 
but when it comes to a question of voiding from 1 . 5 gm. up, the per- 
centage is greatly in favor of the living. Twice as many people 
lived as died of those having albuminuria with granular, or fatty. 
or waxy casts when at the same time they voided more than 1.5 
gm. {23 grains) of phosphoric acid in 24 hours. On the other 
hand, now, three times as many people died as lived when in addi- 
tion to albuminuria with granular, or fatty, or waxy casts they 
voided less than 1 gm. (15 grains) of phosphoric acid in 24 hours. 

Those who thus far are alive voided on an' average 1.8 gm. (28 
grains) of phosphoric acid, whilst those who are dead voided but 
1.14 gm. or about 18 grains. 

It would appear from the above that, when albumin together 
with granular, fatty, or waxy casts is found in the urine of a 
patient, estimation of phosphoric acid is of value as a factor in 
the prognosis. 

Addison's disease: — In the case of a well-known Chicagoan who 
died recently of Addison's disease, repeated determinations of 
phosphoric acid, made by the writer, showed marked deficiency, 
and a high urea-phosphoric acid ratio. The total phosphoric acid 
in the last year of life averaged about 1 gram (15 grains) and 
the ratio of urea to phosphoric acid ranged from 17 to 1 up to 
more than 20 to 1. So far as I know, no one, except Zuelzer, has 
called attention to a high urea-phosphoric acid ratio in this 
disease. 

Nervous diseases: — Less than 1.5 gm. (22 grains) in 24 hours has 
been found by me in the following nervous diseases: Various 
nervous disorders in women, reflex from uterine disease, 10 cases 
out of a total of 13 recorded; neurasthenia, 5 cases; uraemia 
chronica, 3 cases; neurasthenia with tumor, 2 cases; epileptic 
children, 3 cases; hysteria, 3 cases, one in a male patient; in one 
case each of cerebral hemorrhage, paralysis from softening of the 
brain, hypochondria, hemiplegia, oxaluria with mental and nerv- 
ous symptoms, neuritis, feeble-minded state, nervous symptoms 
reflex from genito-urinary disease in a man. 

The smallest excretion was 0.46 grammes, 7 grains, in 24 hours, 
in the case of the man whose nervous symptoms were apparently 
reflex from genito-urinary disease. Small excretions, 0.6 gm. 
each, were noticed in the case of a feeble-minded woman and a 
woman subject to fits. 

Moderate decrease, 1.5 to 2 gm. (22 to 31 grains), was noticed in 
the following: Localized chorea, neurasthenia (3 or 4 cases), par- 
alysis agitans, uricsemia and anaemia, rheumatism, neuritis in a 
neuropath, in an epileptic child, cerebral hemorrhage and hemi- 
plegia, brain symptoms following sunstroke, cephalalgia following 



PHOSPHATES IN URINE. 145 

pneumonia, two cases of nervous disorder reflex from uterus, 
chronic cerebral meningitis and facial paralysis. 

Above 2 gm. , 30 grains, in the following: Melancholia followed 
by suicide (38 to 50 grains), cerebral tumor (32 grains), nervous 
symptoms, reflex from rectal disease (44 grains), torticollis in a 
neuropath, pregnancy (49 grains), epilepsy (42 grains), nervous 
symptoms from worry and abuse of tobacco (43 grains), melan- 
cholia (36 grains), nervous symptoms reflex from uterus (33 
grains). 

MISCELLANEOUS. 

Exophthalmic goitre:— One patient with this disease voided 1.4 
gm., about 20 grains. 

Uterine fibroid:— One woman with a fibroid voided less than 
one gram, 14 grains. 

Cancer: — A woman who died of a cancerous growth voided less 
than one gram, 14 grains. 

Tuberculosis: — A man who died of tuberculosis voided but 0.0 
gm., 10 grains nearly. 

Phosphoric acid in the urine of children: — In view of the dearth 
of information regarding the elimination of phosphoric acid by 
children the following may be of interest: 

Boys:— Infant, 1 year old, slowly sinking from albuminuria, 
hematuria, and uraemia, 2.5 grains in 24 hours (0.15 gramme) 
Boy of 4 years, 10 grains (0.65 gramme). Boy of 6 years, weight 
45 pounds, poorly nourished, 12.5 grains (0.8 gramme). Boy of 9 
years with slight persistent albuminuria without casts, 20 grains 
(1.3 gramme). Feeble-minded boy, 10 years old, 10 grains (0.65 
gm.)- Boy weighing 84 pounds, 25 grains (1.6 gm.). Epileptic 
boy of 10, 24 grains (1.6 gm.). Epileptic boy of 11, 19 grains (1.2 
gm.). Epileptic boy of 12, weight 50 pounds, 40, 32, 27, 27 grains 
(2.6 gm., 2 gm.. 1.76 gm.). Boy with chronic diffuse nephritis, 
11, 14 grains (0.7, 0.9 gm.). Boy of 10, with diabetes mellitus, 40. 
32, 28, 25 grains (2.6. 2, 1.82, 1.6 gm.). Boy of 15, with nocturnal 
enuresis, 21 grains (1.3 gm.). 

Erom this it will be seen (a) that boys with epilepsy or diabete* 
mellitus may void as much phosphoric acid as grown people; (6). 
that boys 10 years old or less may not void more than 10 or 12 
grains of phosphoric acid; (c), that a boy of 4 may void as much 
under certain conditions as a boy of 10 under other conditions. 

Girls: — A healthy female child, 2 years old, voided 16 grains 
(1 gm.) in 24 hours; a girl of 5, with persistent albuminuria (with- 
out casts), voided 6, 7, 10, 13, 14, 15 grains (0.39, 0.4, 0.65, 0.8, 0.9, 
0.95 gm,); a girl of 6 voided 12 grains (0.78 gm.); a girl of 8 voided 
19 grains (1.2 gm.); a girl of 10 voided 17 grains (1.04 gm.); a girl 
of 10 voided 16 grains (1 gm.): a girl of 10, with inflammatory 
rheumatism, voided 20 grains (1.3 gm.); a girl of 12, with diabetes 
mellitus, voided 28 grains (1.52 gm.); a girl, age unknown, voided 
35 grains (2.2 gm.); a girl of 15 voided 28 grains (1.82 gm.). 
19 



146 



URINARY ANALYSIS. 



ACTION OF DRUGS ON ELIMINATION OF PHOSPHORIC 

ACID. 

Potassium bromide, cocaine, and quinine are said to 
diminish phosphoric acid. Salicylic acid and the 
glycerophosphates increase it. 

Cerebral excitants increase the ratio of nitrogen to 
phosphoric acid, cerebral depressants decrease it. 
Among the cerebral excitants are strychnine, small 
doses of alcohol, phosphorus, valerian, cold baths, and 
salt water baths. Among the cerebral depressants are 
chloroform, morphine, chloral, large doses of alcohol, 
potassium bromide, mineral and vegetable acids, pro- 
longed cold baths, Turkish baths, and low temperature. 

CHEMICAL EXERCISE IX. 

1. The student having collected and measured his 
twenty-four hours' urine should proceed to determine 
the total quantity of phosphoric acid in it : 

APPARATUS NEEDED FOR VOLUMETRIC DETERMINATION OF 
PHOSPHORIC ACID IN URINE. 

Two burettes of fifty cubic centimeters capacity, 
preferably those provided with a blue stripe on a white 
background, and with glass stop-cocks. (Fig. 33.) 




Fig. 33. Burettes. 
One burette support (Chacldock) for two burettes 
provided with two milk-glass plates. (Fig. 33.) 



PHOSPHATES IN URINE. 



147 




Fig. 34. 
Bunsen burner. 




Fig. 35. 



One short Bunsen burner with top 
for water-bath, (Fig. 34) and rubber 
tubing. 

One copper water- bath, capacity of 
a pint. 

Three lipped beakers, capacity four 

or five fluid ounces, of size so that they 

may fit quite closely but not too tightly 

into one of the rings of the water-bath. 

Six stirring-rods of the lightest possible weight. 

One 5 c.c. graduate. One 50 c.c. flask. 

(Fig. 35.) 

One pound bottle, each, of the standard solu- 
tions as follows : Uranium nitrate, sodic ace- 
tate, potassic ferrocyanide. (To describe how 
these standard solutions are made would here 
take up too much space.* They may be had' 
ready made, but care must be taken to specify, 
that they are wanted for the phosphoric acid Vo c.c. 
analysis in urine.) Flask. 

METHOD OF DETERMINATION. 

When the twenty-four hours' urine has been col- 
lected and measured, and the result in c.c. noted down, 
fill one of the two burettes with urine and measure off 
exactly fifty cubic centimeters of it into one of the 
lipped glass beakers. 

Add to it just five cubic centimeters of the standard 
sodic acetate solution, using the five c. c. graduate as 
a measure. Stir well with a glass rod. Fill the 
water-bath not quite full of water, set it on the sup- 
port over the Bunsen burner, light the gas, and raise 
the water in the bath to boiling. As soon as it begins 
to simmer, set the beaker containing urine and sodic 
acetate in the water, supported by the ring. The 
beaker should not be fitted tightly into the ring, for 
fear of breaking it, and about one fourth of it should 
be above water. In this way the boiling water con- 
stantly surrounds the liquid in the beaker. While the 
water in the water-bath is being heated, place ten or 

* See appendix for complete instructions. 



148 URINAR Y ANAL YSIS 

twenty drops of the standard potassic ferrocyanide 
solution on one of the clean, dry, milk-glass plates 
forming the foot of the burette stand. The drops 
should be placed singly, and be separate from one 
another on the plate. 

As soon as the water in the water- bath has begun 
to boil, fill the second burette up to the mark exactly 
with the standard uranium nitrate solution. Set the 
burette of uranium solution over the middle of the 
beaker which is on the water-bath, turn the stopcock, 
and let five c.c. of uranium solution run into the 
liquid in the beaker. Stir well with a glass rod and 
transfer a drop of the mixture, by means of the rod 
to one of the drops of the standard potassic ferrocyan- 
ide solution. If a slight reddish color appears the 
operation is over, if not, run in another five c.c. of the 
uranium solution and transfer a drop from the beaker 
again to another drop of ferrocyanide on the plate. 
If no color yet appears, add say another five c.c. of 
uranium solution and try again. If no color even yet, 
then proceed more cautiously adding only two c.c. of 
the uranium solution at a time, stirring well, and trans- 
ferring a drop as before. Finally, if when twenty 
c.c. of uranium solution have been added there is still 
no color obtained on transferring a drop to the fer- 
rocyanide drops, then run in only one c.c. of uranium 
solution until, at last, transference of the drop shows 
the reddish color. 

In urines below 1015 in specific gravity not more 
than fifteen c.c. of uranium solution are, as a rule, 
necessary, and often much less. In the case of urines 
above 1020 in specific gravity, from fifteen c.c. up- 
wards of uranium may be required 

To calculate the amount of phosphoric acid in the 
urine, divide by ten, the number of cubic centimeters 
of uranium nitrate solution, necessary to be added until 
transference of a drop of the mixture in the beaker 
gives a slight but perceptible reddish color with the 
potassic ferrocyanide drop on the plate. The quo- 
tient equals grammes of phosphoric acid per liter of 
urine. Convert this to grains per fluid ounce by 



PHOSPHATES IN URINE. 149 

dividing by 2.125, or simply by consulting table in 
appendix. 

Thus, suppose the urine in twenty -four hours amounts 
to fifty-six fluid ounces (1680 c.c). Suppose the 
amount of uranium solution used was twenty -two cubic 
centimeters: Twenty-two divided by 10 equals 2.2 
grammes of phosphoric acid in every liter of urine, 
and 2.2 divided by 2.125 equals 1.03. Then this 
urine contains 1.03 grains of phosphoric acid in every 
fluid ounce. If there are fifty-six fluid ounces of urine 
then 1.03 times 56 equals 57.68 grains of phosphoric 
acid in the twenty-four hours, or about 3.7 grammes. 

EXAMPLES FOE PEACTICE. 

1 Urine in 24 hours, 30 fluid ounces; number of 
c. c. of uranium used, 17. Kequired grains per fluid 
ounce of phosphoric acid and also grains per 24 hours. 
Answers: 0.S and 24. Convert to grammes per liter 
and per 24 hours. 



2. Urine, 


33-J- fl. oz. ; uranium, 11-J c.c. 


Answers: 


0.5 and 18. 






3. Urine, 


13 fl. oz. ; uranium, 21 c.c. 


Answers: 


1 and m. 






4. Urine, 


38 fl. oz. ; uranium, 11^- c.c. 


Answers: 


0.53 and 20 






5. Urine, 


18-J- fl. oz. ; uranium, 23 c.c. 


Answers: 


1 and 20. 







Comparisons with normal averages may be made by 
remembering, that in health adults pass about one 
grain per fluid ounce of phosphoric acid, or fort} r to 
fifty grains at most in 24 hours. The tables in the 
Appendix are convenient for reference, giving, as they 
do, at a glance the comparison with normal. 

It is my opinion that the English and French observ- 
ers place the normal excretion too high. Sixteen esti- 
mations of the phosphoric acid in the writer's urine 
showed the average quantity to be two-thirds of a 
grain per ounce and 33 grains per %%, hours. 

ft. Urine, 1200 c.c. ; uranium, 14 c.c. Sex, male. 
What per cent of the normal averages, both relatively 
and absolutely? 



150 URINARY ANA LYSIS. 

7. Urine, 800 c.c. ; uranium, 25 c.o. Sex, female. 
What per cent of the normal averages, both relatively 
and absolutely? 

Notes on Manipulation:— 

1. Cochineal as Indicator: — Instead of using potassium ferro- 
cyanide as an indicator, tincture of cochineal may be substituted 
as follows: A few grammes of cochineal granules are digested 
with 250 c.c. of a mixture of 3 volumes of water and 1 volume of 
94 per cent alcohol in the cold. The solution is then decanted and 
a few drops of it added to the 50 c.c. of urine plus 5 c.c. of the 
acetate mixture used. The mixture being heated to the boiling 
point uranium solution is run in until a trace of greenish color is 
noted in the precipitate, which does not disappear on stirring. 

2. Separate determination of the earthy and alkaline phos- 
phates:— 2U0 c.c. of filtered urine are made strongly alkaline with 
ammonium hydroxide and set aside, in a covered dish, for several 
hours, until the earthy phosphates precipitated have settled. The 
supernatant liquid is carefully drained otf and the balance poured 
upon a filter, washed with dilute ammonia (1 part ammonia water 
to 3 of water) and then transferred to a beaker with the aid of a little 
water containing a few drops of acetic acid, a small hole being 
made in the filter. The precipitate is then dissolved in as little 
acetic acid as possible, diluted to 50 c.c. with distilled water and 
titrated with uranium solution. The difference between the total 
amount of P^Ot and the amount now obtained is the quantity of 
phosphoric acid combined with the alkaline earths. 



CHLORIDES IN URINE. 151 



CHAPTER XXII. 



CHLORIDES IN THE URINE. 

Next to urea the most abundant constituent of the 
urine is common salt, chloride of sodium, which, 
together with potassium chloride, forms nearly one- 
quarter by weight of the total solids eliminated by the 
urine. In clinical interest, however, the chlorides are 
inferior to the phosphates. 

Synonyms: — Chlorides; Chloride of sodium, com- 
mon salt: German, Cldornatriuin^Koclisaltzj French, 
chlorure de soude^ set commun. 

Occurrence: — Chiefly as sodium chloride with a 
small amount of potassium, magnesium, and ammon- 
ium chloride. In solution in the urine. Never in the 
sediment. 

Chemical constitution: — Sodium chloride, NaCl, 
common salt. Potassium chloride, KC1, ammonium 
chloride, NII^Cl, magnesium chloride, MgCl 2 , chlorine 
in combination with the bases sodium, potassium, and 
ammonium. 

Cnemical test: — To show the presence of chlorides 
in the urine add ten or fifteen drops of nitric acid to 
10 c.c. (one-third of a fiuidounce) of urine, and then 
a few drops of silver nitrate. A white, curdy precipi- 
tate takes place. Let it settle, pour off supernatant 
urine, add ammonia- water freely, shake well, and the 
precipitate is dissolved. 

Note:— This test depends upon the fact that the chlorine in the 
chlorides unites with the silver in the silver nitrate to form silver 
chloride, according to the equation 

AgNO, + NaCl = AgCl + NaNO,. 
Silver chloride is soluble in ammonia-water. 

The object of adding nitric acid first is to prevent precipitation 
of phosphates. 



152 



URINARY ANALYSIS. 



s±d 



f! 



Determination of quantity of chlorides: — The 

above test may be utilized for determining 
in a rough way whether the chlorides are 
in excess or greatly diminished. The method 
as proposed by Ultzmann is faulty in that 
more nitric acid than a few drops is required 
to prevent precipitation of phosphates, etc. 
The author's method is as follows : Fill a 
percentage tube (Fig. 35), such as is used 
in centrifugal analysis, to the 10 c.c. mark 
with urine. Add not less than 15 to 30 
drops of nitric acid, and then fill up to the 
15 c.c. mark with standard solution of silver 
nitrate, 1 to 8 (one drachm of the crystals 
to eight drachms of distilled water). Mix 
thoroughly, let settle, or better, settle in 
the centrifugal machine.* (See Centrifugal 
Machine). If the bulk of the precipitated 
chlorides is not greater than the fifth or 
sixth mark on the tube, chlorides are con- 
siderably diminished ; if normal, the bulk 
Fig. 36. of the precipitate should reach the tenth to 
Percentage twelfth mark. Results may- be expressed in 
bulk percentage figures, 5 per cent, 6 per 
cent, etc. Inasmuch as for clinical purposes all that is 
wanted is knowledge of a marked diminution in the 
chlorides, or increase after such diminution, the above 
method answers full well. 

[For volumetric quantitative methods (Mohr's, Vol- 
hard's, etc.) see Appendix]. 

Physiology: — The chlorides are derived from the 
food and their daily quantity varies from 10 to 16 
grammes (155 to 250 grains) or a total of from 6 to 
10 gm. (93 to 155 grains) of chlorine. The chlorides 
are, then, next in quantity to urea. Twelve grammes 
(185 grains) may be taken as a common average per 
24 hours but those who are fond of salt may pass 
double this quantity. 

Decrease in chlorides follows deficient nourishment 
and in starvation traces only from the bodily fluids are 

*Use a speed of 1000 revolutions per minute for three miuutes. 



CHLORIDES IN URINE. 153 

found. If at this stage salt food be taken, a portion 
of the salt will be retained in the body until the equi- 
librium is restored; so also after ingestion of large 
quantities of water. Kest diminishes the excretion. 
Beer is said to diminish it also. 

Increase of chlorides will follow any increase in the 
amount of circulating albumin, for on account of the 
great affinity between albumins and salt the latter is 
previously retained by the albuminous bodies. Active 
exercise and copious draughts of water increase the 
elimination, but this increase is likely to be followed 
by retention on account of the albuminous metabolism. 

The chlorides increase and decrease with the volume 
of urine. Common salt is contained in all the tissues 
and secretions of the body, and by its presence metabol- 
ism is increased, secretion stimulated, and it is needed 
for the preparation of some of the secretions, as the 
gastric juice. 

Pathology: — 

A. Diminution of Chlorides: — The chlorides are 
diminished in the following diseases : — 

1. Many acute febrile disorders as pneumonia, 
pleurisy, typhus, scarlatina, roseola, variola, recur- 
rens, acute yellow* atrophy where the diminution runs 
parallel to the height of the fever. 

2. Diarrhoea and Asiatic cholera. 

3. Acute and chronic diseases of the kidneys with 
albuminuria and dropsy. 

4. In chronic diseases generally; a significant 
decrease occurs in anaemia, marasmus, rickets, leu- 
kaemia, chlorosis, also in melancholia and idiocy; in 
dementia, chorea, and pseudo-hypertrophic paralysis 
(less marked decrease) ; chronic hyper-secretion of 
gastric juice, in dilatation of the stomach, in carcinoma 
of the stomach, in ulcer of the stomach; also in im- 
petigo, pemphigus foliaceus ; in chronic lead poisoning. 

Note: — In inflammations with exudation, salt is found in the 
exudation. In croupous pneumonia at the crisis there may be 
but one-hundredth of the normal quantity of salt in the urine. In 
diarrhoeal diseases the bulk of the chlorides is found in the dejec- 
tions. In dropsies the salt is stored up in the dropsical fluid. 
20 



154 URINARY ANALYSIS. 

Intermittent fever is an exception to the rule of diminution of 
salt in fevers; during the paroxysms more chlorides are excreted 
than during the apyrexial period. In acute febrile diseases in gen- 
eral there is (a) less salt ingested (6) retention in the blood due 
probably to increase in the amount of circulating albumin, (c) 
diminished renal secretion of water, (d) possible elimination else- 
where as in diarrhoeas, formation of serous exudates, etc. 

B. Increase of chlorides: — Chlorides may be in- 
creased in the later stages of those diseases in which 
they were greatly diminished at first. After the res- 
olution of exudates and dropsies ; also in diabetes in- 
sipidus (29 gm. in 24 hours); in paralytics in the first 
stage (due to increase of food) ; in potyuria after epi- 
leptic attacks ; in prurigo (29.6 gm.) ; and after chloro- 
form inhalations. 

Clinical notes: — 1 An increase of chlorides in 
acute febrile conditions and especially in pneumonia 
is regarded as a favorable sign. A decrease to 0.05 
gramme in 24 hours is a grave condition. 

2. Potassium salts, notably neutral potassium phos- 
phate (K 2 HP0 4 ), some diuretics, and chloroform in- 
crease the chlorides. Salicylic acid is said to increase 
them temporarily 

3. An elimination of from 10 to 15 grammes daily 
indicates a fair condition of appetite and digestion. 

4. An increase in cases of oedema when associated 
with serous exudates is a good sign. 

5. A continued elimination of more than 15 to 20 
grammes is usually significant of diabetes insipidus. 

EXAMPLES FROM THE WRITER'S OASES. 

In a case of asthma and bronchitis the writer found the chlorides 
about one quarter normal. In chronic nephritis, several cases, 
including one of puerperal nephritis (without convulsions) the 
same low figure was found. Women quite frequently pass com- 
paratively small amounts of chlorides, half to two thirds the nor- 
mal for men, without discoverable serious disorder. One of the 
smallest total quantities of chlorides (about one quarter normal) 
was passed by a man weighing 125 pounds, seemingly in good 
health. In 50 or 60 determinations recently made by the chem- 
ical method described above, but four were above 12 per cent in 
bulk percentage. 

Both large percentage and total quantity, once and a quarter 
normal for a man. were found in the urine of a diabetic nom m. 
In a case of hematuria no increase occurred. The largest per- 
centage ever seen, 18 per cent bulk, occurred in a case of urasmia 
chronica not long before death. 



CHLORIDES IN URINE. 155 

CHEMICAL EXERCISE X. 

The student having collected and measured his urine 
for 24 hours can determine the quantity of chlorides 
in it roughly as follows : 

1. Compare quantity of urine in 24 hours with the 
normal average, and express in per cent of normal. 

2. Determine bulk percentage of chlorides by 
author's method already given, and compare with 10 
per cent — the normal average. 

3. Multiply the figure obtained in 1 by that obtained 
in 2 and compare with 100 as normal. For example, 
suppose the volume of urine in 24 hours is 80 per cent 
of the normal average, and that the bulk percentage 
of chlorides is 5, the latter is about 50 per cent of 
normal. Hence in urine which is about 80 per cent 
of normal volume, we have chlorides about 50 per 
cent of normal percentage, therefore 50 per cent of 
80, or 40, represents the total of chlorides compared 
with 100, which may be assumed to represent the 
normal excretion. In other words the individual is 
passing less than half the normal amount of chlorides. 
This method is only roughly approximate, but serves 
to give an idea as to whether a marked increase or 
deficiency exists. 

4. Observe the difference in bulk of the chloride 
precipitate in the percentage tube when only 5 drops 
of nitric acid are used, and when 15 to 30 drops are 
used to prevent precipitation of phosphates. 

5. See whether addition of 15 drops and of 30 
drops, respectively, of nitric acid makes any difference. 

(For work of this kind Purdy's electric centrifuge 
is useful). 

For research work in chlorides see Appendix. 

APPARATUS REQUIRED. 

Purdy's percentage tubes. Solution of silver nitrate, 1 in 8, say 
20 grammes in 160 c.c. of distilled water (310 grains in 5 fl. oz.). 
C. P. nitric acid. 



156 



URINARY ANALYSIS. 
MICROSCOPICAL EXERCISE in. 



Let a drop of urine dry on the slide and notice the 
dagger-shaped crystals of common salt combined with 
urea. (Fig. 37.) 




A- Chloride of sodium, in combination with urea, 
evaporated quickly from urine. 

B. Chloride of sodium, crystallized from distilled water, 

and resembling oxalate of lime ; never exists in urine, 
and is soluble in water, while the oxalate isnot. 

C. Chloride of sodium crystallized slowly from urine, 

also resembles oxalate of lime, but differs in being 
soluble in water. 

D. Chloride of sodium resembling crystals of cystine 

Fig. 37. Chloride of Sodium Crystals. (John King.) 

The author has noticed in giving microscopical 
exercises to classes that students are oftener puzzled 
by the drying of the drop on the slide, and the appear- 
ance of these crystals than by almost anything else in 
the course. 



INORGANIC SULPHATES IN URINE. 157 



CHAPTER XXIII. 



INORGANIC SULPHATES IN THE URINE. 

Introductory: — There are three kinds of sulphates 
in the urine as follows : 

1. Ordinary sulphates of potassium and sodium, 
called "preformed" sulphates. 

2. Incompletely oxidized sulphates, whose com- 
position is unknown. 

3. Ethereal or aromatic sulphates, called "combined 
sulphates" organic compounds of sulphuric acid with 
indol, phenol, skatol, etc., containing' the radical HS0 3 . 
Already considered. 

The above mentioned sulphates are always in solu- 
tion, never in the sediment. Calcium sulphate and 
magnesium sulphate occasionally occur in the urine, in 
which case they may be found in the sediment. (See 
Sediments.) 

THE PREFORMED SULPHATES. 

Synonyms: — Sulphates : German, Sulfate; French, 
les sulfates. Preformed sulphates : German, Sul- 
pliatschwefelsaure, prdf ormirte Schwef els dure; French, 
lev sulfates preformes. 

Occurrence: — The preformed sulphates are found in 
solution in all normal urine. Of the total sulphates 
the preformed constitute about eight-tenths, the incom- 
pletely oxidized one-tenth, and the ethereal one- tenth. 

Chemical constitution: — The preformed sulphates 
are the ordinary sulphates of sodium and potassium, 
Na 2 SO 4 .10H 2 O, and K 2 SO±. 

Solubility: — Freely soluble in water, hence never 
occurring in the sediment. 

Chemical test and estimation: — To 10 c.c. of urine 
(3 fluidrachms) add a few drops of chemically pure 
hydrochloric acid, and then barium chloride solution, 



158 URINARY ANALYSIS, 

in quantity about one half that of the urine. A white, 
milky precipitate, barium sulphate, is formed accord- 
ing to the equation. 

Ka 2 S0 4 + Ba Cl 2 = Ba S0 4 + 2Na CI. 
Ponr the whole into a percentage tube such as used 
for chlorides, let settle, or better, settle in the centri- 
fuge (speed 1000 revolutions per minute, time 3 min- 
utes), and if the sediment is much below the first mark 
on the tube (i per cent bulk) sulphates are decreased, if 
much above, increased ; if just a little below, about 
normal. 

Kote :— For routine work make up a solution of the 
barium chloride together with the hydrochloric acid 
in water as follows : 

Chemically pure hydrochloric acid, 8 c. c. (10 gm.) 
Chemically pure barium chloride, 40 grammes. ° 
Distilled water, 160 c. c. 

Fill the percentage tube with urine up to the 10 c. c. 
mark and the balance with the barium solution up to 
the 15 c. c. mark. Mix. 

In case a percentage tube is not to be had, try the 
following :— To 10 c. c. of urine in a test-tube add one- 
third its volume of the acidulated barium chloride 
solution; if the turbidity resulting is milky, the sul- 
phates are normal; if creamy, excessive; if merely 
light and translucent, diminished. In the writer's 
experience, three or more students trying this test will 
report two or three different results so that the per- 
centage tube and centrifugal machine are preferable for 
chemical work. For the quantitative analysis of sul- 
phates both preformed and conjugated see Appkndix. 
Physiology:— The mean of the daily quantity of 
sulphuric acid in the urine is 2.6 grammes (38 grains), 
of which that united to form the preformed sulphates 
would be about 2 grammes or 30 grains. The quantity 
of preformed sulphates, as such, would then be about 
3 to 4 grammes (45 to 60 grains). Sodium sulphate 
exceeds in quantity potassium sulphate. The sul- 
phuric acid is derived chiefly from the decomposition 
of proteids, by oxidation of the sulphur to sulphuric 
acid. The sulphates are formed by neutralization of 



INORGANIC SULPHATES IN URINE. 159 

the sulphuric acid by alkalies (neutral phosphates 
transformed into acid phosphates and sodium sul- 
phate). The excretion of sulphates, as a general 
rule, runs parallel to that of urea. The ratio of the 
total sulphuric acid to total nitrogen is 1 to 5 ; to 
urea, 1 to 12. Foods or drinks rich in sulphates or 
oxidizable sulphur compounds, nitrogenous diet, and 
active exercise increase the sulphates in the urine. 
Fasting and vegetable diet diminish them. 

Pathology: — The sulphates are increased in febrile 
diseases, especially pneumonia, meningitis, encephali- 
tis, and rheumatism; in acute myelitis, eczema, dia- 
betes mellitus, and leukaemia. They are diminished 
in chronic diseases of the kidneys. 

PREFORMED SULPHATES AND CONJUGATE SULPHATES. 

1. The ratio of preformed sulphates to conjugate 
sulphates is 10 to 1 (See chapter on Ethereal 
Sulphates). 

2. The excretion of total sulphates is increased by 
animal diet. 

3. In starvation the preformed sulphates are dimin- 
ished, but the conjugate may be increased . 

4. The total sulphates may average 2.46 grammes 
in leukaemia, as compared with 1.51 grammes passed 
by a healthy individual on the same kind of food 
taken in the same amount; 5.8 gm. total may be 
passed before death from acute leukaemia. 

5. In both forms of diabetes, carcinoma of oeso- 
phagus, progressive muscular atrophy, pseudo- hyper- 
trophic paralysis, and eczema, the total sulphates are 
increased. 

EXAMPLES FROM THE AUTHOR'S OASES. 

In the case of a woman with moderate diabetes mellitus without 
marked polyuria and with but 2 per cent of sugar the sulphates 
were relatively and absolutely about half the normal quantity. 
In a case of inflammation of the neck of the bladder in a man they 
were about one-third normal; so also in chronic nephritis in 
several cases. The smallest amount found was in the case of a 
woman already several times mentioned, as having urcemia 
chronica. Not long before deatli in this case the sulphates were 
only about one-sixth the normal total. The highest percentage 
by bulk of sulphates seen^was in the case of a woman, who died of 



160 URINARY ANALYSIS. 

ursemia from diffuse nephritis, about 48 hours before death; the 
quantity was 5 per cent bulk, due doubtless in part to internal 
medication. 

In a severe case of diabetes mellitus in a man the sulphates were 
once and a quarter the normal average bulk; but in an equally 
severe one in a woman they were only one-third normal total. 
I have noticed that when patients with acute or chronic nephritis 
are being flushed out with mineral water that the sulphates in the 
urine are in relative excess compared with other constituents. 
In the case of a man weighing 260 pounds the sulphates were 
barely the normal average both relatively and absolutely. 

In an epileptic boy the sulphates were diminished compared 
with other constituents, being only half normal in total. 

In the case of a man who died, about a month after the analysis, 
from chronic nephritis the sulphates were only one-sixth normal. 

Clinical notes, 

1. It is said that inhalations of oxygen increase the 
sulphates. 

2. The clinical significance of the preformed sul- 
phates and of the incompletely oxidized sulphates is 
slight compared to that of the ethereal sulphates. 

3. Changes in the ratio of the preformed sulphates 
to the ethereal sulphates are of considerable significance. 
Thus, a urine rich in indigo, contains but little of the 
preformed sulphates, and in carbolic acid poisoning it 
is said they may disappear altogether. (Jaksch). 

4. In two cases in which the author found very 
small quantities of preformed sulphates — one-sixth the 
usual average for 24 hours — death took place in a 
month or two. These two were the only ones of 100 
individuals in whose urine the sulphates were less than 
one quarter the usual normal average for 24 hours. 

CHEMICAL EXERCISE XI. 

Determine the quantity of sulphates approximately 
according to the method described under chemical test 
and estimation. Apparatus required : Purdy's per- 
centage tubes and acidulated solution of barium chlor- 
ide as described. 

See Appendix for more accurate quantitative analy- 
sis of preformed and ethereal sulphates. 



INORGANIC SULPHATES ZA URINE. 161 

MISCELLANEOUS INORGANIC CONSTITUENTS. 

Ammonia: — Free ammonia occurs in the urine in traces, which 
are greatly increased by the putrefactive changes. 

Calcium occurs in the urine for the most part as phosphates. 
(See Phosphates). 

Carbon occurs in combination in the urine, forming carbonates. 
Carbonates and bicarbonates of sodium, ammonium, calcium, and 
magnesium are present in minute quantities in fresh urine of 
alkaline reaction, derived from fruit and vegetable acids. Form 
deposits on standing. Calcium carbonate is a rare constituent of 
calculus. Detection: Add an acid to the urine and pass the gas 
given off into lime-water, which becomes turbid. (See Sediments). 

Carbonic acid, as a gas, occurs in normal urine in the propor- 
tion of from 4 to 9 volumes of free gas; 2 to 5 combined. 

Fluorine, in small quantity, is said to be present in urine. 

Iron occurs in normal urine in small quantities, but in what 
form is yet unknown. 

Nitric acid: — This inorganic substance in combination forming 
nitrates occurs in small quantities in the urine, probably originat- 
ing from the drinking-water and the food. Meat diet diminishes 
and vegetable increases. The average amount is about 42.5 milli- 
grammes per liter. In decomposing urine nitrites may be found. 
Schaffer's test (potassium ferrocyanide and acetic acid) is suffi- 
cient for qualitative research; Trommsdorf colorimetric method 
for quantitative. 

Nitrogen:-— The free gases of the urine are chiefly carbonic 
acid, oxygen, and nitrogen, which are in small proportion and 
may be withdrawn by the air-pump. Nitrogen in combination 
is found in urea, uric acid, kreatinin, hippuric acid, etc. 

Oxygen may occur free, in small quantities, in urine, from 
which it may be withdrawn by the air-pump. 

Peroxide of Hydrogen, H 2 2 , inorganic, has been found in 
traces in fresh urine, disappearing as decomposition sets in. 
Tincture of indigo and dilute solution of ferrous sulphate serve as 
a test, the color of the indigo being discharged by the peroxide. 
81 



162 URINARY ANALYSIS. 



CHAPTER XXIY. 



ABNORMAL CONSTITUENTS OF URINE; PROTEIDS. 
The proteids found in urine are the following : 

Serum-albumin; 

Serum-globulin (paraglobulin); 

Albumoses [peptones]; 

Fibrin; 

Haemoglobin; 

Histon; 

Nucleo-albumin (mucin); 

In addition to these, egg-albumin may be found after 
diet rich in eggs. 

SERUM-ALBUMIN. 

Synonyms. German, Albumin, Eiweissstoff\ 
French, Albmnine. 

Chemical Constitution: The formula is not known. 
It belongs to the true albuminoid substances which do 
not contain phosphorus except as calcium phosphate. 
It contains carbon, hydrogen, nitrogen, and oxygen. 
Rich in sulphur. 

Occurrence: It occurs in the urine only in solu- 
tion, never in the sediment. Probably does not occur 
at all in normal urine except in mere traces. 

Form: It belongs to the colloids, uncrystallizable, 
and does not penetrate animal membranes under normal 
conditions. 

Properties: — Serum-albumin is soluble in water, 
dilute acids, and alkalies. Solutions of serum-albumin 
have a specific rotatory power of — 56°, and are coag- 
ulable at temperatures of from 50° to 90° C, (122° to 
144® F.) according to the solvent. Solutions of serum- 
albumin are precipitated by the addition of large 
quantities of mineral acids or by metallic salts, as 
silver nitrate, mercuric chloride, etc. Also by alcohol 
but not by sodium chloride or sodium carbonate. 



ALBUMIN IN URINE. . 163 

Serum-albumin resembles closely egg-albumin differ- 
ing, however, in two respects (a) it is not coagulated 
by ether (b) when coagulated by heat it is more readily 
soluble in excess of nitric acid than is eg-cr-albumin. 
Albumin is converted into alkali- albumin by the action 
of alkalies, as sodium or potassium hydroxides, and 
into acid- albumin by the action of acids, as hydro- 
chloric and acetic. 
Reactions: 

1. Alcohol precipitates serum-albumin from urine 
containing it. 

2. Nitric acid added drop at a time precipitates 
albumin, but the precipitate disappears on shaking 
after addition of each drop, until a certain amount of 
acid has been added, after which the precipitate is not 
dissolved by shaking; but when great excess of acid 
has been added the precipitate is dissolved. 

3. Boiling the urine coagulates albumin in it, if the 
urine be acid, not if alkaline. 

4. Acetic acid, citric acid, and vegetable acids gen- 
erally do not precipitate albumin. 

5. Boiling the urine previously acidified with acetic 
acid will coagulate the albumin, provided the acetic 
acid is not in excess. 

6. Boiling the urine, previously acidulated with 
acetic acid, and to which strong solution of common 
salt or sulphates of sodium or magnesium have been 
added, will coagulate the albumin. 

7. Albumin is precipitated from urine containing it, 
without heating, on addition of potassium ferrocyanide 
solution and strong acidulation with acetic acid. 

8. Albumin is precipitated from urine containing it 
by a great number of solutions, as for example, those 
of chromic acid, picric acid, potassio-mercuric iodide, 
sodium tungstate, trichloracetic acid, metaphosphoric 
acid, silver nitrate, etc. 

Inasmuch as many of the substances mentioned 
above precipitate other substances, besides albumin, 
from the urine, much depends on the method of appli- 
cation of the tests, which will be described in full 
further on. 



164 . URINARY ANALYSIS. 



CHAPTEK XXV. ■ 

A CLINICAL TEST FOR SERUM-ALBUMIN. 

Too much stress cannot be laid on the importance 
of technique in albumin testing, especially when the 
physician is unfamiliar with microscopical work. I 
endeavor to drill my classes so that they can detect 
even a trace of albumin in the* urine. This cannot be 
done by everyone readily and easily, and some few 
men can never be depended on to recognize albumin 
when present in but small quantities. 

TECHNIQUE OF ALBUMIN TESTING. 

1. Filter the freshly voided urine. It is important 
that the urine be freshly voided, because in all stale 
urine what seems to be a trace of albumin can be found 
by the test I shall now describe. It is important to 
filter the urine since, by filtration, sedimentary mat- 
ters, interfering with the test, are removed. More- 
over, it is said that in certain urines the reaction due 
to mucin may mislead in unfiltered urine. 

In order to filter the urine, fold three small, white, 
cut filter papers twice, the second time at right angles 
to the first. Insert the papers into a small glass fun- 
nel, set the tube of the funnel into a tall, narrow test- 
tube, and pour the urine into the funnel-shaped pouch 
made by the filters. [I advise use of three papers rather 
than one, because in my experience nearly all freshly 
voided urine filters clear through three thicknesses of 
paper. More are not advisable, because, of danger of 
traces of vegetable albumin.] 

The urine filters slowly through into the test-tube 
and is clear. Let it fill the tube three-fourths full. 
Wipe off the outside of the tube with a rag until it is 
entirely clean and ' bright. Hold the tube up to the 
light, and see that both tube and urine are entirely clear 
and transparent. 



TESTS FOR ALBUMIN. 165 

2. Boil the upper stratum of the urine in an alcohol 
lamp flame. This is done by holding the tube by the 
closed end with the thumb and forefinger of the right 
hand, inclining it over the flame in such a way that 
the latter heats the urine about half an inch from the 
surface of the liquid. Use an alcohol flame so as not 
to crack the tube by too great heat. Do not let the 
flame at any time touch the tube above the surface of 
the liquid. Nearly all beginners fail to observe this 
precaution, with result that the tube is decapitated, so to 
speak, loses the upper quarter as neatly as if chopped off. 

Boil thoroughly thirty seconds, removing from flame 
whenever the urine threatens to boil over, but do not 
boil the lower half of the urine at all. 

3. Add three to six drops of twenty per cent acetic 
acid to the boiling urine. Shake to and fro gently 
until acid and upper stratum of urine have thoroughly 
mixed, then boil again for, say, thirty seconds. 

4. Hold the tube against a dark background, as the 
coat-sleeve, or better still, hold it below a window sill 
of a north window or any window where there is no 
direct sunlight. 

RESULTS. 

A. If albumin is present, the upper, heated, acidulated 
quarter, or possibly third, is now distinctly turbid as 
compared with the lower, cool, remaining portion of 
the urine. If much albumin is present, the whole up- 
per third or half of the urine is milky and flocks soon 
begin to fall. If only a moderate amount of albumin 
is present, the upper quarter or third is cloudy. If 
there is a distinct turbidity which cannot be seen when 
the tube is held up to the light we call it & plain trace. 
If there is an indistinct turbidity of the same charac- 
ter, requiring careful adjustment of eye and back- 
ground, in order to see it, we call it a trace. If the 
turbidity is faint and only seen with great difficulty 
we call it & faint or doubtful trace. Such faint traces 
may possibly be due to mucin and not to albumin at 
all. They may be observed in the urine of nearly all 



166 URINAR Y ANAL YSIS. 

women. [Women who have leucorrhoea are nearly 
always found to have anywhere from a faint to a plain 
trace of albumin by this test in their urine. In such 
cases a vaginal tampon should be used, before the 
urine is voided for examination, or a cleansing vaginal 
injection taken.] 

B. If no albumin be present in the urine, nothing 
will be seen, the upper, heated, acidulated portion of 
the urine resembling the lower in appearance. 

C. If the urine be of deficient acidity, it will become 
cloudy when heated, owing to precipitation of earthy 
phosphates. The addition of six drops of the acetic 
acid and gentle to and fro shaking will usuallv dissolve 
thephosphatic cloudiness, and the urine becomes nearly 
clear, in cases when albumin is absent, but more cloudy 
still if albumin is present 

JSFow, in nearly all cases when the acetic acid appar- 
ently dissolves the phosphatic cloud, careful observa- 
tion will show a faint haze to remain. If this haze is 
really faint, and is not appreciably increased by further 
heating, I usually assume serum-albumin to be absent. 
Why not, it is asked, add the acetic acid first to the 
urine before boiling? When albumin is present in 
small quantities in acid urine, acidifying still further 
makes the albumin soluble when the urine is boiled, 
so that there would always be need to take the reac- 
tion beforehand, and to use judgment as to the amount 
of acid to be added, and so on. 

If now, after boiling, a cloudiness appears, which, 
however, apparently disappears when acetic acid is 
added, but if after further boiling, a cloudiness in the 
upper portion is now again plainly seen, a plain trace 
of albumin is present, which was not seen at first, 
owing to the phosphatic cloudiness, and may not in 
the end be as noticeable as was the phosphatic cloudi- 
ness. Do not mistake a ring-shaped coagulum of 
phosphates remaining half way down the tube for 
albumin. This merely means that the acetic acid hag 
not yet reached the lowest stratum of phosphatic 
cloudiness. The coagulum of albumin is to be seen in 
the upper part of the tube, always, when it is present. 



TESTS FOR ALBUMIN. 167 

Lastly, in strongly alkaline urine which foams when 
the acetic acid is added, be not sparing of acid, for the 
albumin in it is alkali-albumin, and will not be fully 
coagulated by heat until the alkalinity is overcome by 
the acid. In such cases, which are not very common, 
if freshly voided urine is tested, add ajcetic acid, drop 
by drop, and take reaction of the upper quarter with 
blue litmus paper, continuing to add acid until the 
blue slip is turned bright red, then boil again. 

REMARKS. 

For adding the acetic acid a medicine dropper (Fig. 
38) is useful. Three drops may be added to urines 



Fia. 38. Medicine-dropper. 

which do not become turbid on boiling, but five or six 
will be necessary in cases where a cloud appears with 
heat alone. 

The object of adding acetic acid is two-fold, first, 
to dissolve any phosphatic cloudiness; second, to con- 
vert alkali-albumin into albumin coagulable by heat. 

The advantages of acetic acid over nitric acid are 
two-fold, first, the acid is neither dangerous nor cor- 
rosive ; second, it does not act on the coloring matter 
of the urine as does nitric acid. Plain traces of albu- 
min shown by the heat and acetic acid test appear as 
faint or doubtful traces when the heat and nitric acid 
test is used. 

DISCUSSION. 

The possible sources for error in my test are mucin and resins. 
Kirk claims that mucin alone will answer to the te>t but Saundby 
has failed to confirm his statement. So far as my own observa- 
tion goes, I find that the urine of women will sometimes show a 
trace by my test, which other tests, as for example, Purdy's salt 
and acetic acid, do not confirm, yet microscopical examination, of 
the sediment in such cases reveals presence of leucorrhcea. It is 
said, moreover, that when the patient is taking tolu, balsam of 
Peru, etc , that heat and acetic acid will precipitate the resin. 
Alcohol, however, will dissolve this precipitate. For clinical pur- 
poses, therefore, I regard the test as useful, and open to less criti- 
cism than any of equal readiness, simplicity, and expense. 



163 URINAR Y ANAL YSIS. 



CHAPTER XXYI. 



LIFE-INSURANCE TESTING FOR ALBUMIN. COLD NITRIC 
ACID TESTS. 

In this chapter and in the one following the physi- 
cian will find the tests for albumin commonly recom- 
mended to examiners by life insurance companies. 
Under each test will b© considered the following • 

1. Technique of the test; 

2. Chances for error; 

3. Different methods of applying the test; 

4. Practical objections or advantages. 

Since most companies still prefer the older tests — 
those with nitric acid, heat, or both — special promi- 
nence will be given them in these pages. 

Preparing the Urine for Examination: — Before 
the urine is tested for albumin it must first be clear. 

To make the urine clear proceed as follows : — 

A. The nrine is already clear or but slightly turbid 
and of either acid reaction or but slightly alkaline : — 

Filter through three filter papers folded together. 
In a large majority of cases this is all that is neces- 
sary, especially in the case of freshly voided urines. 

B. The urine does not filter clear through three 
filters : — 

Shake the filtered urine with magnesia usta and filter 
again. This will usually suffice to clear it. 

C. The filtered urine is still turbid. 

If after the operations described in "A" and "B" 
the urine is still turbid add to it, after filtering as in 
B r half its volume of a ten per cent solution of potas- 
sium hydroxide (caustic potash) and toil. It becomes 
cloudy from precipitation of phosphates. Filter and 
in most cases the bacterial debris which has made it 
turbid will be precipitated with the phosphates and 
will remain on the filter, the urine coming th rough clear. 



TESTS FOR ALBUMIN. 169 

D. The filtered urine is still turbid. 

Add to it a few drops of magnesian fluid, toil, and 

filter again. 

Note: — Magnesian fluid may be made by dissolving 100 grammes 
(1554 grains) each of pure magnesium sulphate and ammonium 
chloride in 800 c.c. (27 fluidounces) of distilled water with addition 
of 100 c.c. (3 fl. oz) of ammonia water. 

Different albuminous substances in urine: — In 

order to avoid confusion it must be understood that 
the urine may contain different albuminous substances. 
These are : 

1. Serum-albumin and serum-globulin. These 
occur together and are coagulated both by heat (boil- 
ing), and by mineral acids, as nitric acid. 

2. Albumoses (propeptones), may occur with or 
without serum-albumin. Are coagulated by mineral 
acids but not by boiling. Peptones are now not 
thought to be present in urine. 

3. Nucleo-albumin (mucin) may occur with or with- 
out serum-albumin ; not coagulated by boiling. Pre- 
cipitated by strong acetic acid, especially in diluted 
urine. 

The term albuminuria is applied to the voiding of 
urine containing serum -albumin. Albumosuria to 
that containing the albumoses. In addition to the 
substances named above the urine may contain 
Jmmoglobin, fibrin, and histon, which will receive 
special attention later on. 

A. THE COLD NITRIC ACID TEST. HELLEft's TEST. 

I. Usual method of application: — Pour half an 
inch of pure, colorless nitric acid into a test-tube, hold 
the latter inclined as in Fig. 39 (see page 170), and let 
an equal quantity of clear urine trickle down the inside 
of the tube. The urine floats on the surface of the acid. 

Results: — If serum-albumin is present a sharply - 
defined, zone of whitish color will be observed at the 
point of contact between the acid and the urine, 
becoming more or less pronounced according to the 
amount of albumin present. If but little albumin is 
32 



170 UBINAR Y ANAL YSIS. 

present, it may be necessary to hold the tube against, 
a dark back-ground, as the coat-sleeve, in order to see 
the zone. 




Fig. 39. Nitric acid test. 

If no zone be seen, set the tube aside for half an 
hour or more. A trace of albumin may then be seen 
which is not visible at first. 

Chances for error: 

1. A generally diffused haziness does not indicate 
albumin. If the latter is present a distinctly and 
clearly -formed white ring is seen, provided the test be 
carefully performed without too hasty pouring of urine 
into acid. 

2. A cloudiness not at point of contact but higher up, 
more diffused and spreading downward is not albumin, 
but due to precipitation of urates especially in urines 
of high specific gravity. In case of doubt perform 
the test again as follows : Dilute the urine with two 
or three times its volume of water, warm the nitric 
acid before adding the urine and now no cloud will be 
seen, if the previous cloud was due to urates. 

3. A light cloudiness near the surface of the urine 
is not albumin but due to nucleo- albumin (mucin). 

4. In all urines a transparent zone of color, more or 



TESTS FOR ALBUMIN. 



171 



less intense, appears. This is not albumin but clue to 
oxidation of the normal chromogens of the urine by 
the acid. The color is violet, reddish, or brownish, 
and its transparency can be observed by holding the 
tube up to the light. 

5. A zone of slowly forming crystals may be 
observed in urines of high specific gravity containing 
3 per cent or more of urea. The crystals are nitrate 
of %irea and. will not form if the test be tried again 
with dilute urine and warm acid as in 2. 

6. A yellowish- white zone, less plainly defined than 
the albumin ring may be due to precipitation of cer- 
tain resinous bodies, such as those contained in turpen- 
tine, balsam of copaiva, tolu, storax, cubebs, salicylic 
acid, etc., taken by the patient. Shake the urine- 
acid mixture with alcohol, which will dissolve the 
resins but not affect coagulated albumin. 

7. If blood is present, the albumin ring will be col- 
ored brown-red; if bile, greenish or blue. 

8. If the nitric acid contains nitrous 
acid as an impurity, bubbles will rise, 
even in acid urine, and may obscure the 
rings. These bubbles are probably due in 
acid urine to decomposition of urea by 
nitrous acid. In alkaline urine the bub- 
bles are due to carbon dioxide liberated 
from carbonates present by action of the 
acid, and will hence always be seen even 
if the nitric acid be free from nitrous acid, 
and no decomposition of urea take place. 

Different methods of applying the test: 

1. The Truax-Greene albumin tester:— By use of 
this instrument (Fig. 40) the various rings are seen 
better than when a test-tube is used. 
Fig. 40. Albu- o The use f conical glasses. C. E. Simon recom- 
min tester, mends the use of conical glasses as follows: 
About 20 c.c. (5 fluidrachms) of the clear urine are poured into 
one of the glasses and from 6 to 10 c.c. (1$ to 2£ fluidrachms) of 
nitric acid added by means of a pipette which is carried to the 
bottom of the vessel, when the acid is slowly allowed to escape by 
diminishing the pressure of the finger on the tube. 

Results:— If albumin is present a whitish ring is seen from 
below upward at the zone of contact. If albumin is small in 
amount, the upper border, in time, though at first as well-defined 



A~ 




172 ^ URINARY ANALYSIS. 

as the lower, becomes less so, the cloudiness extending upward in 
the form of small, irregular columns. 

If excess of uric acid is present, after 5 or 10 minutes a distinct 
ring appears from above doivnward in the clear urine, about 1 to 
2 centimeters (Mnch to an inch) above the zone of contact. The 
degree of excess is indicated by the size of the ring. 

If uric acid is deficient the ring above the zone of contact does 
not appear within 5 or 10 minutes. 

If excess of urea is present an appearance like hoar-frost is seen 
on the sides of the glass. In such a case urea is 25 gm. per liter 
(12 grains per ounce) or more. When not less that 45 gm. per liter 
(22 grains per ounce) are present, spangles are seen. When urea 
is 50 gm. per liter (25 grains per ounce) or more, a dense mass of 
the urea nitrate may be seen to separate. 

If the urinary pigment is normal, a transparent colored ring is 
obtained, of peach-blossom red, varying in tint from a faint rose 
to a pronounced brick color. 

If urobilin is present a color ring like the above will be seen but 
the tint is mahogany. 

If indican is present, a more or less violet-colored ring is seen 
above the peach blossom ring of normal color. The color of the 
indican ring varies from light blue to deep indigo according to the 
amount of indican present. 

If bile be suspected, add a little nitrons acid to the nitric and a 
series of colors will be noticed from above downward, yellow, 
green, blue, violet, and red, of which the green is characteristic. 
Bile absent, no green. 

Note:— Nitrous acid may be readily made by boiling a piece of wood with 
the nitiic acid. 

If albumin and bile together are present the bile color-play is 
beneath the albumin ring. 

If albumin, globulin, and the albumoses are all present there 
is a cloud at the zone of contact as in case of albumin. If no 
cloud, probable absence of all three. 

If albumoses alone are present, remove the cloudy urine (precip- 
itated by the acid as above) with a pipette and heat. Urates are 
dissolved by gentle heat, albumoses by a higher temperature, 
reappearing on cooling while the urine turns yellow. 

If albumin and albumoses together are present, the yellow 
color is noted as above, but the urine is only partially cleared by 
heat. 

If resins are present, the turbidity produced by nitric acid is 
cleared by alcohol. 

3. Alexander's Method. To distinguish albumin, nucleo-albu- 
min (mucin), and resins Alexander proceeds as follows: Three 
glasses are used and into each is poured 8 or 10 c.c. of urine:— To 
the first glass is added 2 or 3 drops of hydrochloric acid; if resins 
are present a red-violet coloration is seen when the mixture is 
heated. 'To the second glass is added strong acetic acid: — a precip- 
itate insoluble in excess, indicates mucin. To the third glass 
after heating is added half its volume of nitric acid: a turbidity 
indicates albumin. 

Practical advantages and disadvantages: — 

1. Heller's test is a very convenient and simple one 
for clinical purposes. 



TESTS FOR ALBUMIN. 173 

2. It is said to preciptate sioth of one per cent of 
albumin. 

3. It precipitates various albuminous substances, 
resins, urates, urea (excess), and oxidized chromogens, 
but not phosphates, true peptones, or vegetable alka- 
loids. 

4. The chief practical objection to it is the corro- 
sive character of the nitric acid. 

B THE NITKO-MAGNESIAN TEST 

1. Preparation: — Saturate distilled water with 
chemically pure magnesium sulphate, filter, and to the 
clear filtered liquid add nitric acid. 

Note: — The amount of nitric acid used varies according to those 
who use this test. Dr. Roberts uses 1 volume of nitric acid to 
5 of magnesium sulphate solution. Others use 1 of nitric acid to 
2 of the magnesium sulphate. Some examiners prefer equal parts 
of acid and magnesium solution. 

2. Method of application: — The contact method as 
in case of Heller's test. 

3. Advantages and disadvantages: — The testis 
said to be as delicate as Heller's while the liquid is less 
corrosive. It is however, a more delicate test for 
nucleo-albumin and the ring of the latter is nearer the 
chemical fluid than in Heller's test. 



174 URINAB Y ANAL YSIS. 



CHAPTER XXYII. 



LIFE INSURANCE TESTING FOR ALBUMIN— CONTINUED. 
HEAT TESTS. 

Among the most important tests for albumin we 
find:— 

C. THE HEAT AND NITRIC ACID TEST. 

This test was the first ever used for albumin in the 
urine by Cotugno in 1770. The nrine is boiled and 
nitric acid is added to it. It is performed in several 
ways : — 

Method I : — Fill a test-tube half full of clear nrine, 
hold it with a test-tube clamp, boil, and add one-tenth 
its volume of nitric acid. 

Results: — If any cloudiness, coagnlum, or precipi- 
tate is seen after boiling and addition of nitric acid, 
albumin is present. 

Method II : — Boil about an inch of the clear urine 
in a test-tube and add 2 or 3 drops of ten-per-cent 
nitric acid solution. If, after a few moments, there 
is no cloudiness, coagulum, or precipitate, boil again, 
add ten drops more of the dilute nitric acid and set 
aside. A trace of albumin may become visible after 
an hour or so, not seen at first. 

Method III : — Clarify the urine by addition of a 
few drops of potassium hydroxide solution, boiling, 
and filtration. Fill a test-tube half full of it and add 
15 to 18 drops of strong nitric acid. If the urine 
contain albumin it will become somewhat cloudy. Boil 
and let stand half an hour. There will be seen a 
sediment of whitish flakes or granules. Boil again, 
when if albumin be present, the flakes will not be 
dissolved by the second boiling. 



DISCUSSION. 



Authorities are not agreed as to the best method of performing 
the heat-and-nitric-acid test. Those who employ method I. do so 



TESTS FOR ALBUMIN. 175 

because (1) too small an amount of nitric acid may dissolve 
coagulated albumin, hence add to the urine one-tenth its volume 
of acid and not less; (2) too large an amount of the acid may also 
dissolve the albuminous coagulum to a certain extent, hence use 
not more than one-tenth its volume of acid. 

Chances for error: — 1. While the urine is hot. 
albumoses, urates, and vegetable alkaloids are not pre- 
cipitated by this test. Urine rich in urates may on 
cooling, precipitate a pinkish-red sandy precipitate of 
uric acid. 

2. The resins, thymol, etc., are precipitated by this 
tsst, but the precipitate is soluble in alcohol. The 
latter should not be added until the urine cools for 
fear of explosion. 

3. When only a trace of albumin is present the 
characteristic appearance is either the formation of a 
few flakes of coagulated albumin or of a general 
turbidity which finally results in a fine nocculent 
separation, persisting when the solution is hot, and 
rendered more pronounced by the addition of alcohol. 

4. If albumoses are present, the urine turns dis- 
tinctly yellow after addition of nitric acid, and, on 
cooling, a whitish precipitate appears. 

5. Faint hazes may be due to nucleo-albumin 
(mucin). See differential testing further on. 

D. HEAT AND ACETIO AOID TEST. 

The writer advises that this test be used as described 
under the "Clinical Test," in Chapter XXY, namely, 
boiling the upper third and adding acetic acid. 

If the acetic acid be added drop by drop after boil- 
ing, there is little or no danger that the albumin will 
be dissolved by excess. Resins may be excluded hy 
use of alcohol. So far as the writer has been able to 
observe the chief chance for error is due to precipita- 
tion of what is probably nucleo-albumin (mucin). In 
case a slight cloudiness is obtained, not by heating, 
but only after addition of several drops of acid and 
further boiling, it may be well to try the following : 



176 URINARY ANALYSIS. 

E. ACETIC ACID AND HEAT TESTS. 

I. Purely raises the specific gravity of the urine 10 or 15 degrees 
by addition of a little saturated solution of common salt, filters 
clear, and to a test-tube two-thirds full of urine add 1 or 2 drops 
of 50 per cent acetic acid, and boils the upper third. He claims — 
and with reason I think — that by this test mucin is not coagu- 
lated, since this body is soluble in a strong solution of common 
salt. 

II. Heynsius acidulates the clear urine strongly with acetic 
acid, then adds a few c.c. (about one fluidrachm) of saturated 
solution of common salt. The urine is then boiled, when a floc- 
culent precipitate indicates presence of albumin. 

III. The clear urine may be treated wuth a few drops of acetic 
acid until a distinctly acid reaction is obtained, and then one-sixth 
its own volume of a saturated solution of sodium chloride, mag- 
nesium sulphate, or sodium sulphate added. On boiling the urine 
a precipitation of even minimal amounts of albumin will take 
place. 

CHEMICAL EXERCISE XII. 

1. To one volume of albuminous urine add six vol- 
umes of water. Mix well, fill a test-tube half full of 
the mixture, add a drop or two of nitric acid and shake : 
albumin will be precipitated but will reclissolve on shak- 
ing. Keep on adding nitric acid, drop by drop, until 
finally the precipitated albumin is not dissolved. 

This experiment shows that in dilute albuminous 
solutions a small quantity of nitric acid does not com- 
pletely precipitate the albumin. In urine the neutral 
salts help small quantities of the acid to precipitate the 
albumin, but it is not safe to rely on the use of two or 
three drops. 

2. Boil a sample of albuminous urine of acid reaction : 
a cloudiness appears which is undissolved by either 
acetic or nitric acid. 

3. Boil a sample of albuminous urine to which 
liquor potassaa has been added : the urine becomes 
turbid: filter; boil again. The urine remains clear. 
Now add acetic or nitric acid in quantity sufficient to 
overcome the alkalinity and an abundant whitish coag- 
ulum of albumin appears. The first turbidity was due 
to precipitation of the phosphates. After filtering, 
although the urine was boiled, no coagulum of albumin 
appeared because the liquor potassas had converted the 
albumin into what is called alkali- albumin, not coag- 



TESTS FOR ALBUMIN. 177 

ulated by heat. Addition of acid, however, broke up 
the alkali- albumin and then the albumin was coagulated 
by heat. 

4. Let a sample of abundantly albuminous urine 
grow stale and ammoniacal. It will then be seen on 
boiling that only a slight turbidity due to phosphates 
appears, but on addition of acid, albumin will be coag- 
ulated and an abundant precipitate appear. 

5. Filter a sample of acid urine containing but little 
albumin, fill each of the two test-tubes f full of it and 
boil the upper third of each. To one add 15 to 30 
drops of nitric acid after boiling, and to the other 2 
or 3 drops of acetic acid. Which shows the precipi- 
tated albumin the plainer? 

6. Compare either or both of these tests with the 
cold nitric acid test, using (a) the Truax- Greene appar- 
atus, (b) a test-tube and pipette and (c) conical glasses 
and pipette. 

7. To 10 c.c. of a sample of albuminous urine of 
acid reaction add 5 c.c. of 20 per cent acetic acid, boil, 
and compare with other samples to which acetic acid 
is added after boiling in various amounts. 



178 URINARY ANALYSIS. 



CHAPTER XXVIII. 



LIFE INSURANCE TESTING FOR ALBUMIN.- Continued 



THE FEREOCYANIO AND TRICHLORACETIC TESTS. 

F. The ferrocyanic test: — There are several 
methods of applying the ferrocyanide test, as follows : 

Method I : — Make a solution of chemically pure 
potassium ferrocyanide, 10 grammes in 200 c.c. of 
distilled water (L 55 grains in 7 n\ oz.) Into the bottom 
of a clean test-tube pour 15 to 30 drops of acetic acid 
(30 per cent), then add two or three times that amount 
of the ferrocyanide solution and shake. The mixture 
should remain clear. .Now add clear filtered urine, 
and if albumin be present it will be precipitated 
throughout the whole volume of the urine in the form 
of a more or less milk-like flocculent cloud, according 
to the quantity of albumin present. 

Method II : — Fill an ordinary test-tube half full of clear filtered 
urine and add 3 or 4 c.c. (a fiuidrachm or so) of the ferrocyanide 
solution. Mix thoroughly and add 10 or 15 drops of acetic acid, 
and, if albumin is present, a cloudiness or coagulum will be 
plainly seen. 

Method III:— A few c.c. of urine are strongly acidulated with 
acetic acid (sp. gr. 1064). If (a) there is no turbidity, further add 
a few drops of a 10 per cent solution of potassium ferrocyanide, 
when if albumin be present, either a faint turbidity or a precipi- 
tate, according to quantity of albumin present, will be seen. 
Compare with tube containing clear filtered urine, both tubes 
being held against a dark background. 

If (o) there is a turbidity seen on addition of the acetic acid 
alone (urates or mucin), the urine to which the acetic acid has 
been added should be filtered and diluted before the ferrocyanide 
is added. 

Method IV: — The test by contact is as follows: To five cubic 
centimeters (one and a third fiuidrachm) of 30 per cent acetic acid 
add five drops of the ferrocyanide solution, and cause the mixture 
to trickle down the side of a test-tube in which are 5 c.c. of clear 
filtered urine. A white ring at the surface of contact between 
the two fluids indicates the presence of albumin. 



TESTS FOR ALBUMIN. 179 



CHANCES FOR ERROR. 



1. The ferrocyanide solution should be freshly made 
in pure distilled water, filtered clear, kept in a clean 
bottle, with a clean stopper, away from the light. 

2. It is well to see that the acetic acid and the fer- 
rocyanide solution when mixed together without urine 
remain clear. 

3. The writer has noticed that, if the acetic acid be 
added from a pipette with a rubber nipple, a cloudiness 
or precipitate sometimes takes place. If pipettes are 
used they should be all glass. . 

4. Heating will cause a precipitate in the mixture 
without addition of urine. 

5. When the amount of albumin is very small, cloudi- 
ness is not seen immediately after adding the urine but 
only after a few minutes have elapsed. 

6. The ferroc3 T anide test precipitates albumin, globu- 
lin, acid and alkali-albumins, albumoses; nucleo- 
albumin from bile is said to be precipitated by it. 

7. Urines of high specific gravity should be diluted 
with water lest albumin and albumoses be not pre- 
cipitated. 

8. Removing the coagulated substance with a pipette, 
and boiling it, will tell whether it is albumin or albu- 
moses, since the latter clears when boiled and reprecip- 
itates on cooling. 

Partial clearing on boiling indicates a mixture of 
albumin with albumoses, but some care during the pro- 
cess is necessary, since boiling decomposes the ferro- 
cyanide solution and makes it cloud} 7 . The best way 
to manage it is to let the precipitate settle thoroughly, 
decant supernatant liquid, add water, let settle again, 
and remove with the pipette. This can be done 
rapidly by the use of the centrifugal machine. 

G. The Trichloracetic Acid Test: — Trichloracetic 
acid, CClj.COOH, is a substance derived from acetic 
acid by treatment with chlorine in sunlight or by 
oxidizing chloral with nitric acid. 

It is a monobasic acid, HO.Cl^O^ and occurs in 
commerce in the form of crystals. 



180 URINARY ANALYSIS. 

Method of application: — Make a saturated solution 
of the crystals, (half an ounce in an ounce of distilled 
water) and by means of a pipette carry 1 or 2 c. c. 
( 16-32 minims) to the bottom of a test-tube contain- 
ing the clear filtered urine so as to form a layer beneath 
the urine. If albumin be present, a white ring will be 
seen to form at the zone of contact between the two 
fluids, varying in intensity with the amount of albu- 
min present. 
Chances for error: — 

1. Albumoses are precipitated but disappear upon 
boiling, to reappear on cooling. 

2. Dilution of the urine prevents mistake which 
may be due to precipitation of urates ; heat also serves 
to distinguish these substances. 

3. Alkaloids, if precipitated, are soluble either by 
heat or by large excess of the reagent. 
Advantages: — 

1. This test will demonstrate albumin in urines in 
which the more common tests yields negative results 
but in which tube-casts may nevertheless be found. 

2. Although showing 1 part of albumin in 100,000 
of urine, the test is not so delicate as to demonstrate 
traces of nucleo-albumin in all urines. 

3. Trichloracetic acid will detect albumin which has 
escaped observation on account of being dissolved by 
acetic acid, and not precipitated by picric acid or by 
heat. 

4. No color rings are formed in the urine when this 
test is used. 



TESTS FOR ALBUMIN. 181 



CHAPTER XXIX. 



MISCELLANEOUS TESTS FOR ALBUMIN 

Inasmuch as different teachers prefer to teach medi- 
cal students different tests I subjoin a list of a num- 
ber of albumin tests with the hope that it will include 
all in common use. 

Acidulated brine test:— This test as performed by Roberts is as 
follows: Make a saturated solution of sodium chloride and mix 
one pint of it with one fluidounce of strong hydrochloric acid (500 
c.c. with 30 c.c.). Filter and apply by contact method, floating 
the urine on the reagent. 

Chromic acid test:— Mix one part of a five per cent solution of 
chromic acid with three parts of urine in a test-tube. If albumin 
is present a cloudiness appears. If the mixture remain clear, boil 
the upper portion and a slight trace of albumin will be thus 
detected by cloudiness appearing in the heated portion. The 
chromic acid must be chemically pure, and the distilled water 
used for dissolving it also free from impurities. 

Metaphosphoric acid, Hindenlangs test: — Into the clear filtered 
urine drop a fragment of metaphosphoric acid and, if albumin be 
present, a white precipitate is formed. 

Picric acid test:— Make a saturated solution of picric acid, 6 or 
7 grains to the ounce, of boiling distilled water. Float two inches 
of the reagent on a column of urine four inches deep. As far as 
the yellow color extends the coagulated albumin renders the 
mixture turbid. Albumin, peptone, mucin, urates, albumose, 
kreatinin, vegetable alkaloids, and piperazine are all precipitated. 
Hence add solution of citric acid (20 grn. per liter) first filter to 
eliminate mucin, then add picric acid, and carefully heat the pre- 
cipitate formed. If albumin is present heat does not dissolve the 
coagulum as in the case of other bodies. The heat must not be 
too great or other precipitates will be formed. 

Piperazine picrate is crystalline and disappears on heating. 

Potassio-inercuric iodide test:— This test is performed with 
what is known as Tanrt's solution, potassium iodide, 3.32 
grammes; mercuric chloride, 1.35 grammes; acetic acid, 20 cubic 
centimeters; distilled water to make 100 cubic centimeters. Dis- 
solve the two salts separately and then mix the solutions, add 
the acetic acid, and make up the whole to 100 c.c. with distilled 
water. Appl} r by contact method, floating the urine on the 
reagent. Gentle heat distinguishes albumin, pine-acids, and 
mucin from possible precipitates of albumoses and vegetable 
alkaloids. 

Phenic-acetic-acid test:— This test as used by the late Dr. 
Millard of New York is performed with the following solution: 



!82 URINARY ANALYSIS. 

Glacial carbolic (phenic) acid, 95 per cent, 2 fluidrachms; acetic 
acid, C. P., 7 fluidrachms; liquor potassae. 6 fluidrachms. Float 
the urine on the reagent. Heat distinguishes albumin, mucin, 
and pine-acids from albumoses and alkaloids. 

Platinocyanide of potassium:-Same as the ferrocyanide test, 
and has the advantage of being a colorless solution. 

Sulphocyanide of potassium:— Take 100 c.c. of a ten percent 
solution of sulphocyanide of potassium and 20 c.c. of acetic acid, 
and add a few drops to the urine to be examined. If it contains 
the smallest quantity of albumin, a distinct cloudiness is at once 
obtained; if the urine contain much albumin a thick white pre- 
cipitate is obtained. Any excess of the reagent has no effect. 
All normal urines, that is to say, such as are not affected by fer- 
rocyanide of potassium and acetic acid, give negative results with 
this reagent. By successive dilutions of urine containing albu- 
min it is found that this reaction is more delicate than ferrocyan- 
ide of potassium and acetic acid. It possesses the advantage of 
being colorless, so that the least cloudiness is more manifest than 
when ferrocyanide is used. Succinic acid may be substituted for 
the acetic acid. If to albuminous urine sulphocyanide of potas- 
sium and a little succinic acid be added, a distinct cloudiness is 
obtained, while normal urine remains clear. 

This reaction possesses the advantage of being easily carried 
about, the sulphocyanide of potassium and the succinic acid being 
solid. If these reagents be mixed in equal proportions, and a 
small portion of the mixture be added to albuminous urine, an 
immediate cloudiness results with the smallest quantity of 
albumin. 

Reaction of albumin with percliloride of mercury and acetic 

acid:— If a feu- drops of a ten per cent solution of percliloride of 

mercury be added to albuminous urine a distinct cloudiness is 
obtained, while in normal urine the cloudiness is hardly visible 
except in very exceptional cases. If to the urine so rendered 
cloudy by percliloride of mercury, a few drops of acetic acid be 
added the precipitate disappears if it is not composed of albumin. 
On the contrary, if the urine contains albumin, the precipitate 
persists. A mixture of one part of acetic acid and a ten per cent 
solution of percliloride causes only a cloudiness when there is 
albumin in the urine; this appears immediately on the addition 
of the reagents and does not form a deposit, while the addition of 
the sublimate alone causes one. Peptones give no reaction with 
these agents in the proportions above indicated. The same ap- 
plies to uric acid, urea, phosphates, and sugar. Further, very 
concentrated urine does not become cloudy on the addition of the 
sublimate and acetic acid. 

Spiegler's test for albumin:— Spiegler's very delicate test for 
albumin in urine consists of a test solution composed as follows- 
Percliloride of mercury, 8 grams; tartaric acid, 4 grams; su°ar* 
20 grams; distilled water, 200 grams. The sugar serves to raise 
the specific gravity of the liquid to 1060. winch is higher than 
that of nearly all urines. It is used by placing some of it in a 
test-tube, and gently adding some of the urine to be tested If 
albumin is present a ring will form at the junction of the two 
liquids. The reaction will not take place in solutions of egg or 
serum-albumin save in the presence of chlorides. 

The sulpho-salicylic acid test:— This test was first described 
by Reoch, and used independently by Mac William. It is said to 



TESTS FOR ALBUMIN. 183 

show traces of albumin in a dilution of 1 to 50000. Sulpho-sali- 
cylic acid, C 7 H 6 S0 6 = C e H,.S0 8 .H(OH) COOH, is a white, crys- 
talline substance, made by heating salicylic acid with concen- 
trated sulphuric acid. It precipitates all proteids. It may be 
used either in form of a saturated solution, or by adding some of 
the crystals to a small quantity of filtered urine in a test-tube. In 
the latter case the tube should be shaken. If albumin is present 
in acid urine, a cloudiness or white homogeneous precipitate, 
according to the amount of proteid present, appears. Uniform 
opalescence is characteristic of this test. The test must be supple- 
mented by heat to the boiling point, in order to distinguish the 
the serines from the albumoses, the latter being dissolved by heat 
as in the urine of the third stage of pneumonia, and the first 
passed after ejaculation of semen. The urine must be acid, or the 
test fails. Sulpho-salicylic acid gives no mucin reaction in normal 
urine, but only when larger quantities of mucin are present. 

Sodium tuiigstate (Oliver's Test): — Mix equal parts of a 1 to 4 
solution of sodium tungstate and saturated solution of citric acid. 
Apply by contact. Albumoses, mucin, and occasionally urates 
are also precipitated, but heat clears all but mucin and albumin. 

Jolles's test:— This is said to detect 1 part albumin in 120.000 
of water. The constituents are mercuric chloride, 10 grams; suc- 
cinic acid, 20 grams; sodium chloride, 10 grams; water 500 c.c. 

Sharp's test:— Dr. Sharp substitutes glycerol for the sugar in 
Spiegler's test. 

Tanret's reagent: — Potassium iodide, 3.32 gm.; mercuric 
chloride, 1.35 gm. ; acetic acid, 20 CO.; distilled water, q. s. 
100 c.c. 
Millard's reagent: 

95 per cent carbolic acid f 3 ij 

Glacial acetic acid. 3 v ij 

Liquor potassas .3 xxij 

Mix. 



CHEMICAL EXERCISE XIII. 

For five or six consecutive exercises the student 
should test urines for albumin, using some one test, 
until thoroughly familiar with it. The author advises 
either the heat and acetic acid, or heat and nitric acid 
tests to be used first. After familiarity with one or 
the other of these is gained, try either the trichlora- 
cetic acid test, the ferrocyanic test, or the sulpho-sali- 
cylic acid test. 



184 URINARY ANALYSIS. 



CHAPTER XXX. 



THE QUANTITATIVE DETERMINATION OF ALBUMIN IN 
THE URINE. 

Clinical methods only will be considered in this 
chapter. A favorite one involves use of the 
Esbacli tube (Fig. 41), which is a specially 
constructed tube which has an upper mark R, 
a second mark below it, U, and the figures 7, 
6, 5, 4, 3, 2, 1, one above the other, indicat- 
ing graduations of the tube, in parallel lines, 
beginning just below U, and going down to 
nearly the bottom of the tube. Between the 
mark 1 and the curved bottom of the tube is 
a short mark, not numbered, which is -J- of 1. 
In order to use the tube, first add eight or 
ten drops of the 20 per cent acetic acid to, say, 
half a fluid ounce (15 c.c.) of the urine to be 
tested, mix well, and pour the mixture into the 
Fio 41 ^ u ^ e untu tne latter is filled to the line indi- 
Esbach cated by the letter U. Then fill to the mark 
tube. R with Esbach's reagent, a liquid made by 
dissolving 155 grains (10 grams) of picric acid and 
310 grains (20 grams) of citric acid in 30 fluid ounces 
(900 c.c.) of distilled water and, after solution is 
accomplished, adding enough distilled water to make 
the total one litre (1.05 quart, or a little over 33 fluid 
ounces). The solution should be made in cold water 
and the chemicals powdered in a mortar before solution 
is attempted. 

After the yellow reagent fluid has been added, close 
the mouth of the tube with the thumb, and invert a 
dozen times without shaking. Then close with a 
rubber cork and let settle for 24 hours. The precipi- 
tated proteids, if present, settle down to the bottom 



TESTS FOR ALBUMIN. 185 

of the tube, and the height of the deposited mass may 
be measured by the lines, 1, 2, 3, 4, etc., on the out- 
side of the tube. The inventor, Dr. Esbach, claims 
that these lines indicate percentages of albumin by 
weight, viz.: 1-10, $-10, 3-10, etc., of one per cent by 
weight. These figures must be carefully distinguished 
from the old-fashioned method of reckoning albumin 
roughly by bulk, namely, 10 per cent, 20 per cent, 
etc., after boiling with heat and nitric acid. One per 
cent of albumin by weight is a very large quantity, but 
one per cent by bulk is an exceedingly small quantity, 
not much more than a plain trace. The Esbach tube 
is graduated so as to express percentages by weight, 
not bulk, arid this must not be forgotten. I have, 
however, for clinical purposes, discarded reckoning by 
the Esbach tube save in the following way : 

1. The precipitated proteids settle down below mark 
1, albumin is small in quantity. 

2. The precipitated proteids settle down below 3 
but above 1, albumin is moderate in quantity. 

3. The precipitated proteids settle down to any 
figure or letter above 3, albumin is abundant, very 
large in quantity if 5 to 7, enormous if much above 7. 
In such cases dilute the urine with an equal volume of 
water and multiply. In general it is better to dilute 
the urine, so that its specific gravity does not exceed 
1008. It is said that albumoses and kreatinin are pre- 
cipitated by the Esbach liquid, and a crop of uric acid 
crystals is often seen. 

Separation of albumin and globulin: — First deter- 
mine the total proteids by use of Esbach 's albumin- 
imeter, then saturate another portion of the urine 
with magnesium sulphate, filter, and determine the 
albumin in the filtrate with the Esbach tube again. 
The difference in the two results represents the amount 
of globulin precipitated by the magnesium sulphate, 
but allowance must be made for increase in the volume 
of the urine caused by saturation with the sulphate. 
24 



186 



URINARY ANALYSIS. 




For a rack in which to set Esbach tubes the 
writer finds the metallic one (Fig. 42), conveni- 
ent, since the Esbach tubes are too large to fit 
the apertures in many of the test-tube racks 
used. 

For the determination of small quantities of 
albumin the original Esbach tube is not well 
suited. Dr. Hayward, of Liverpool, has modi- 
fied the tube so that the base is conical, instead 
of round, by which means a small bulk of albu- 
min may be measured. 

Determination of albumin by use of per- 
centage tubfS: -Dr. C. W. Purdy, of Chicago, 
has our thanks for devising percentage tubes 
for the determination of albumin. They are 
the same as those already spoken of under 
chlorides (Fig. 35), and may be used either with 
or without the centrifugal machine. When the electric centri- 
fuge is used, the determinations may be made at a definite speed 
tor a definite time, for example, at 1000 revolutions per minute 
for five minutes. Purdy directs that a percentage tube be filled 
to the 10 c.c. mark with filtered urine, 3.5 c.c. of a 1 in 10 solu- 
tion of potassium ferrocyanide added, and the mixture shaken, 
then 1.5 c.c. of 30 per cent acetic acid solution poured in, and 
the whole mixed thoroughly. Let stand 20 minutes and settle in 
the centrifuge. Settle for five minutes at a speed of 1000 revolu- 
tions, or till no further decrease in bulk of the precipitate occurs. 
Results are expressed in terms of balk, not weight. If the sedi- 
ment, for example, setths down to the mark 2 c.c , we have 20 
per cent by bulk. If to the second small line, 2 per cent bulk. 
These percentages do not correspond to percentages from boiling. 



Fig. 42. Rack. 



CHEMICAL EXERCISE XIV. 



THB WRITER'S EXPERIMENTS IN DETERMINING BULK PERCENTAGES 
OF ALBUMIN.' 

Collect the twenty-four hours' urine of an albuminuric patient, 
filter a few hundred cubic centimeters of it, and for all experi- 
ments use 10 c.c. of this filtered urine, and a speed of 1,000 
revolutions per minute in the centrifuge for five minutes. To 
different samples of the filtered urine add the following reagents 
respectively: 

1. Purdy's ferrocyanic mixture as previously described. 

2. Five c.c. of the Esbach fluid, previously acidulating the urine 
with 3 to 10 drops of 20 per cent acetic acid, according to reaction. 

3. Boil the urine and then add 3 to 10 drops of 20 per cent acetic 
acid. 

4. Boil the urine and add 20 drops of nitric acid. 

5. Add 0.2 gm. of trichloracetic acid. 

6. Add 2 gm. of trichloracetic acid— (solubility in excess), 

7. Add 0.2 gm. of sulpho salicylic acid. 

8. Add 2 gm. of sulphosalicylic acid. 

9. Add 0.2 gm. of metaphosphoric acid. 

10. Add 2 gm. of metaphosphoric acid. 

11. Add 5 c.c. of Oliver's sodium tungstate solution. 






TESTS FOR ALBUMIN. 187 

12. Add 5 c.c. of Jolles's test solution. 

13. Add 5 c.c. of Tanret's reagent solution, 
14 Add 5 c.c. of Millard's test soluth n. 

15. Add 5 c c. of Spiegler's test solution, or of the Spiegler- 
Sharp test liquid, etc. 

All sorts of variations may be tried, especially in the way of 
adding small quantities of each reagent, and comparing results 
with those obtained by using an excess of the reagent. The differ- 
ence in bulk between coagulated and precipitated albumin may 
be shown. The effect on the sediment of higher speed should 
next be shown, each sediment being subjected to a speed of 1,700 
revolutions a minute for five minutes. It will be found that no 
two of the bulks will exactly agree, and that between the abund- 
ant precipitated bulk where the Esbach fluid is used, and the 
small coagnlum obtained by heat and acetic acid, there is a 
marked difference in percentage. 

The student will notice peculiarities of specific gravity and 
density, for example, the precipitate obtained by the ferrocwanic 
test is lighter apparently than that of some of the others. A 
small percentage, say 3, obtained by the ferrocyanic test at 1,000 
revolutions can be reduced one-half by a speed of 1,700. If the 
quantity of proteids is very large, heat and acetic acid, or 0.2 gm. 
of sulpho-salicylic acid produce a denser sediment of smaller bulk 
than do the ferrocyanic, trichloracetic, or Esbach tests, at a speed 
of 1,000. When the amount of albumen is large, a speed of 1,700 
for 15 or 20 minutes may be required to settle the precipitate 
properly. 

Subject all the precipitates, settled at a speed of 1,000 per 
minute, to one of 1,700 per minute for 5 minutes and note which 
ones shrink in volume, and how much. Now pour off the super- 
natant urine in every tube (which can readily be done without 
losing any of the sediment), fill up to the 15 c.c. mark with cold, 
distilled water, shake well until all the sediment is dislodged, 
using a knitting needle or a small glass rod for stirring purposes, 
and settle again at a speed of 1,700 for five minutes. It will be 
found that this procedure reduces the percentage bulk of some of 
the sediments. Pour off the supernatant cold water and add hot 
water (above 150° F.), shake and stir as before, and settle while 
still warm at a speed of 1,700 revolutions. It will be seen that 
hot water reduces the bulk percentages materially in some cases. 
I*et cool and after stirring and shaking, settle again at 1,700 and 
it will be found that, in some cases the proteid is not reprecipi- 
tated, on cooling, to its full previous bulk. 

CLINICAL NOTES ON AUTHOR'S CASES. 

1. In a case of persistent albuminuria without other symptoms, 
and with but few casts in the urine, determination of the quantity 
of albumin, by the different reagents mentioned above, showed 
the following: Two examinations of the 24 hours' urine, made 
two weeks apart, showed about 4 per cent bulk of albumin by the 
heat and acetic acid, and by the heat and nitric acid tests, respec- 
tively, each time. On the other hand the ferrocyanic test showed 
8 per cent the first time, and 14 per cent two weeks later; the tri- 
chloracetic test, precisely the reverse, namely, about 15 per cent 
the first time, and 8 per cent the second. In other words, the 
results were identical when the methods involving heat and acid 



n 



188 URINARY ANALYSIS. 

were used, but contradictory between the ferrocyanic and tri- 
chloracetic acid tests. 

2. In a case of albuminuria, due to presence of pus and blood in 
the urine, the small bulk percentages obtained by use of the vari- 
ous reagents agreed quite closely. 

3. In a case of chronic Bright's disease, ten days before death, 
when albumin was very large in amount in the urine, heat and 20 
drops of nitric acid gave bulk percentages, which agreed more 
closely with those obtained by the precipitating reagents, than 
was the case in other urines containing small bulks of albumin. 

4. The writer suggests to all teachers, who have the electric 
centrifuge, to encourage original work in the determination of 
bulk percentages of albumin, in order to answer the following 
questions: (a) Is the centrifugal method capable of yielding suffi- 
ciently constant results to be at all available for clinical purposes? 
What reagent or method gives the most satisfaction, i. e., is most 
reliable? (b) Can the separation of albumin, globulin, and albu- 
moses be made and the ratio of these substances to one another 
approximately determined? 

N. B — The influence of the specific gravity of the urine on the 
bulk of the precipitates should be studied, and the size of the 
flakes observed, when boiling is used. Serum-albumin can be 
separated from globulin by rendering the urine amphoteric or 
faintly alkaline with sodium hydrate, and then saturating with 
magnesium sulphate in substance. Globulin is precipitated and 
serum-albumin remains in the filtrate. Determine the bulk per- 
centage of the serum-albumin, by means, say, of boiling and 
addition of acetic acid, and by other reagents which do not react 
with magnesium sulphate. 

For the Gravimetric Determination of Albumin see 
Appendix. 



SIGNIFICANCE OF ALBUMINURIA, 189 



CHAPTER XXXI. 



CLINICAL SIGNIFICANCE OF ALBUMINURIA. 

Albumin occurs in the urine without serious signifi- 
cance much often er than was formerly supposed, but 
at the same time the permanent presence of albumin in 
the urine must on the whole always be regarded as 
pathological. We may classify the various albuminu- 
rias not due to pus or blood as follows : — 

1. Functional Albuminuria: — This much -abused term describes 
a number of albuminurias which in the past have been regarded 
as physiological, to wit: transitory, intermittent, or cyclical albu- 
minurias. Albuminuria may follow severe muscular or mental 
exercise, cold baths, hearty meals, etc., and disappear; or it may 
continue several days or even weeks, disappear and reappear 
again. In the latter case the albuminuria is called intermittent. 
If it disappear and reappear with regularity, it is called cyclical. 
Cyclical albuminuria is called postural when it disappears after 
rest in bed, to appear again when the person stands on his feet. 

These albuminurias may be observed in apparently healthy per- 
sons, but the writer is skeptical about any physiological basis for 
them. Among certain young men, whom the author has had 
under observation for years, no death has as yet occurred, and no 
disease of the kidneys can be demonstrated, but, as a rule, the 
subjects are pallid or neurasthenic and, in some cases, sexually 
weak. 

Transitory albuminuria is noticed in anaemic children and mas- 
turbating boys. It is also found in pregnancy and in parturition. 

Urines containing abundant sediments of uric acid or oxalate of 
lime are quite frequently found to contain albumin also. The 
latter most always disappears, when the urine becomes normal in 
other respects. 

2. Albuminuria due to febrile disorders:— This in the experi- 
ence of the general practitioner deserves second place. The albu- 
min is seldom abundant, and disappears as the temperature 
becomes normal. 

3. Albuminuria due to renal disease itself:— Far more com 
mon than has hitherto been recognized. Should be placed second 
in the list of any specialist who does not see many acute febrile 
diseases. The essential diagnostic features are, (a) increase in the 
quantity of night urine compared with the day, (o) decrease in the 
excretion of phosphoric acid, (c) presence of albumin in both day 
and night urine, (d) presence of casts, especially when in abund- 
ance, and of various kinds, (e) and presence of renal epithelium 
which, C. Heitzmann holds, is alone diagnostic of nephritis. 



190 URINARY ANALYSIS. 

4. Albuminuria of various chronic diseases:— In these cases 
the kidneys are perhaps free from anatomical lesions, but the 
patient is himself suffering from some malady or other. The 
patients are weak, nervous, or anaemic. They often have diarrhoea. 
To this class belong pallid, ill-nourished young persons subject to 
various complaints as headache, nervousness, dyspepsia and diar- 
rhoea. The albuminuria may be chronic, but is curable. Iu the 
writers experience it is fairly common among medical students, 
and especially among those who are either pallid in appearance, 
or nervous. 

Many maladies are attended by presence of albumin in the 
urine, such as epilepsy, tetanus, mental diseases, painful paroxys- 
mal affections of the abdominal organs (various colics), incarcer- 
ated hernia, etc., etc. 

The writer has found albumin quite constantly in the urine of 
epileptics, even when seminal fluid is absent, not only after par- 
oxysms but persistently. 

5. Albuminuria from circulatory disturbances as in cardiac 
insufficiency from valvular lesions, degenerations of the heart, 
coronary disease, impeded pulmonary circulation affecting the 
right heart, compression of renal veins by tumors, the pregnant 
uterus, etc. It is probable that febrile albuminuria is circulatory 
to a certain extent, due to renal hyperaemia produced by increased 
or diminished blood pressure. 

The albuminuria of various choleras and in the simpler forms of 
intestinal catarrhs are, according to Simon, doubtless dependent 
upon such causes. 

6. Hsemic albuminuria:— Albuminuria due to various diseases 
of the blood as in purpura, scurvy, leukaemia, pernicious anaemia, 
syphilis, jaundice, diabetes, oxaluria, uricaemia; in poisoning by 
mercury and lead; after inhalations of ether and chloroform. 

7. Albuminuria from mechanical pressure or interference:— 
An impeded outflow of urine from the kidneys due to ureteral 
stenosis, impaction of calculus, pressure of tumor on ureter, etc.. 
may be followed by albuminuria. 

8. Toxic albuminuria: — Albuminuria may follow direct irri- 
tant action of poisons on the renal parenchyma. Substances like 
iodine, phosphorus, arsenic, lead, antimony, mineral acids, nitre, 
carbolic acid, oil of turpentine, cantharides, mustard, salicylic 
acid, tar, petroleum, alcohol, balsam of copaiba, cubebs, etc., etc. 

In acute febrile diseases the albuminuria may be partly due to 
the direct irritant action of bacterial poisons. 



CLINICAL NOTES. 

1. Albuminuria due to presence of pus, blood, or 
leucorrhceal fluid in the urine: — By far the most 
common of all seen in routine practice. In the 
urine of nearly all married women a trace of albumin 
may be found, or at any rate traces of a substance 
which responds both to the author's heat and acetic 
acid test and to the ferrocvanic test. Albumin is 



SIGNIFICANCE OF ALBUMINURIA. 191 

found in greater or less quantity in the urine of most 

all elderly men, due to pus from bladder or prostatic 

troubles, also in the urine of young men who have 

had gonorrhoea, and its complications. 

Note:— This form of albuminuria is known as false, or adventi- 
tious. 

2. The writer has found by observation of the mor- 
tality among 500 patients with albuminuria, which 
have been carefully traced up to 1896, that, when the 
night urine unaccountably equals the day in quantity, 
the chances are very great that the patient has Bright's 
disease; and when the night urine habitually exceeds 
the day in quantity, the chances are three to one that 
Bright's disease is present. 

Again it has been found that when the quantity of 
phosphoric acid falls below 20 grains (1.3 gm.) per 
diem, the chances are great that the albuminuria is of 
renal origin. When the phosphoric acid falls below 
15 grains (1 gm.) the probabilities of rapidly fatal 
renal disease are greater than those of recovery. 

Furthermore, by the author's heat and acetic acid 
test albumin unaccountably found in both day and 
night urine is likely to be renal in origin. 

3. In typical cases of contracting kidney, as those 
with retinitis, soon terminating fatally, albumin may, 
however, either not be found at all in the morning 
urine, voided on rising, or may be present in traces 
only. In a case of this kind which the writer saw 
with Dr. C. Gurnee Fellows, a few months before 
death of the patient, albumin and casts were absent 
from the urine voided on rising, but present in the 
urine voided during the day. 

4. Albuminuria not of renal origin occurs according 
to Dr. J. Hubley Schall of New York, as follows : 
In 31 cases (out of 510 recorded analyses) in neuras- 
thenia, epilepsy, dilatation of the stomach, morphine 
habit, obesity, malassimilation in children, and after 
laparotomy. Bouchard finds it in obesity, gout, and 
diabetes. Schall finds intermittent albuminuria in 
physicians due to mental and physical excesses. Phos- 
phaturia was marked in four cases and there was slight 



192 URINARY ANALYSIS. 

excess of sulphates. Hawkins of London, reports a 
case of a physician who had albuminuria 43 years, 
without other symptoms of Bright' s disease. Inter- 
mittent albuminuria, not of renal origin, may be due 
to elaboration of certain albuminoids by the liver, to 
excitation of the cutaneous nerves, to venous stasis from 
paralysis of the veins, as in morphine habit, to malaria, 
neurotic family history, prolapsus uteri, and, tempo- 
rarily, as a result of over-study or powerful emotions 
in neurasthenic individuals. 

5. According to Schall, diet seems to have no appre- 
ciable effect on the albumin in the cases just mentioned. 
Milk increases it, but kumyss has a tendency to im- 
prove the general condition and, in two cases, de- 
creased the albumin. [This would seem to suggest an 
intestinal cause for the disturbance in view of the 
action of kumyss on aromatic sulphates See Ethereal 
Sulphates]. 

6 Dy A. "W Stirling, of Atlanta Georgia, exam- 
ined 369 boys between the ages of 12 and 16 on one 
of the large training ships near London. Nearly 21 
per cent had albumin in their urine three hours after 
getting out of bed in the morning. Of the boys who 
played in a band 60 per cent had albuminuria Albu- 
min increases with age. In 92 cases between 5 and 94 
vears of age, from 20 to 30 years the percentage was 
only 10; from 50 to 60, 6Q".6 per cent; 60 to 70, 75 
per cent; 70 to 80, 75 per cent; 80 to 90, 83 per cent. 



PROTEIDS IN THE URINE. 193 



CHAPTER XXXII. 



PROTEIDS CONTINUED. GLOBULIN, ALBUM03ES, [PEP- 
TONE], HAEMOGLOBIN, FIBRIN, HISTON, 
NUCLEO-ALBUMIN. 

The proteids other than serum-albumin found in 
urine do not possess the clinical interest which attaches 
itself to albumin. A summary of our knowledge in 
regard to them may be given as follows : 



k cr 



SERUM-GLOBULIN. PARAGLOBULIN. 

Detection in urine: 

Method 1, — Reader the urine alkaline with ammonium hydrate, 
so as to precipitate phosphates. Let settle for an hour, filter, and 
to the filtrate add its own volume of a saturated solution of 
ammonium sulphate. If globulin be present, a no 'culent, white 
precipitate occurs A yellowish or pinkish precipitate of ammo- 
nium urate may also form, but is distinguishable by its color. 

Method 2. — Render* the urine alkaline with sodium hydrate, 
filter, and carefully pour the filtrate down the side of a test-tube 
containing a saturated solution of sodium sulphate, so as to form 
a layer above this. If serum-globulin is present a white ring will 
appear at the zone of contact. Patorts test. 

Method 3. — Dilute 30 to 50 c.c. of clear filtered urine with 10 
times its volume of water. Add dilute acetic acid and pass into 
the solution a stream of carbonic acid gas. A turbidity, eventu- 
ally becoming a precipitate, indicates the presence of globulin. 

Method 4. — Drop albuminous urine, drop by drop, into a large 
•volume of water. Each drop as it falls is followed by a milky 
streak if globulin is present. 

Method. 5. — Daiber separates globulin from albumin as follows: 
The urine is poured into a vessel and mixed with an excess of abso- 
lute alcohol, which precipitates all the albuminous substances. 
This mixture is left to settle for some hours, then filtered and 
washed with lukewarm, distilled water, then the deposit, together 
with the filter paper on which it is collected, is deposited in an- 
other vessel and distilled water at 30° C. (86° F.) is added and, 
drop by drop, diluted acetic acid up to complete dissolution of the 
albuminoid substances. After filtration a solution of 1 part sodium 
carbonate in 4 parts distilled water is added, until the solution 
becomes perfectly neutral or slightly alkaline, and then a 50 per 
cent solution of ammonium sulphate, which precipitates the glob- 
ulin in the form of a flaky, white deposit. This latter may be dis- 
solved in a 1 per cent solution of sodium chloride from which it is 
again precipitated when the liquid is treated. The globulin 
25 



194 TJRINAR Y ANAL YSIS. 

remaining in the ammonium sulphate solution may be extracted 
as a precipitate by boiling; the liquid. 

Quantitative determination:— 

1. In a rough way, Paton's test (method 2 above) will show by 
the size of the ring, whether much or little serum-globulin is 
present. 

2. Collect on a dried and weighed filter the precipitate, obtained 
by method 1 above, with ammonium sulphate after it has settled 
for about an hour. Wash thoroughly with a solution of ammo- 
nium sulphate, one half saturated, until a sample of the washings 
treated with acetic acid and potassium ferrocyanide no longer 
gives a precipitate. Wash with alcohol and with ether to remove 
any fats present, and dry at 120° to 130° C. (248° to 266* F.) until 
it ceases to lose weight. The difference in weight, between the 
dry filter without precipitate and with it, represents the quantity 
of serum-globulin in the volume of urine used. 

3. The Esbach tube may be used, as already described in the 
Chapter on Quantitative Determination of Albumin. 

Clinical Significance: — 

1. Globulin is not found in normal urine. 

2. Its occurrence without serum-albumin is very 
rare, if it occurs at all without it. 

3. The amount of globulin compared with that of 
albumin is increased in albuminuria due to digestive 
disorders, in chronic catarrhal cystitis, in acute 
nephritis and especially in lardaceous disease (amyloid 
degeneration of the kidney), and in the albuminuria 
of pregnancy in which the globulin may exceed the 
albumin. 

4 The amount of globulin, compared with that of 
albumin, is decreased in chronic nephritis 

Clinical Notes: — 

1. The lower the state of nutrition of the renal 
epithelium, the more likely it is that globulin in 
increased amount will pass through it. (Boyd). 

2. The proportion in which globulin is usually asso- 
ciated with albumin varies, so that it is not possible to 
determine the variety of renal disease by it. Even in 
lardaceous disease it may not be in excess. (Boj^d). 

3. In the albuminuria of heart disease the globulin 
is usually more abundant than in chronic interstitial 
nephritis. (Boyd.) 

4. Senator holds that an increase of the globulin- 
albumin ratio is a fairly constant symptom of lardace- 
ous disease, and is of some diagnostic importance 



PROTEIDS IN THE URINE. 195 



ALBUMOSES. 



The first products of the hydration of the native 
proteids are known as proto and hetero-albumose. 
The product most resembling peptone is called deutero- 
albumose. It is probable that there are a large num- 
ber of albumoses, varying slightly according to the 
particular native albumin from which they are derived 
and the antecedents leading to their formation. , 

The albumoses, or proteoses as they are also called, 
are products of the digestive action of proteolytic fer- 
ments on all forms of proteid matter; they are the 
most important of the primary bodies resulting from 
gastric and pancreatic digestion. They are also pro- 
duced by the growth of bacterial organisms and many 
of the toxic substances resulting from the growth of 
pathogenic bacteria, are peculiar albumoses. It is 
probable that the albumoses found in urine owe their 
origin to pyogenic micro-organisms, as the staphylo- 
coccus pyogenes aureus, although it is equally prob- 
able that the pneumococcus and streptococcus pyogenes 
are, likewise, active agents in the same direction. 
There is no question about pus containing albumose. 

Albumoses thus formed under such different condi- 
tions, while resembling each other in their chemical 
properties, are not possessed of identically the same 
physiological properties. 

Serum-albumin and globulin by hydration, as possi- 
bly from pepsin, frequently present in the kidneys 
and urine, may frequently be accompanied in the urine 
by traces of albumose. 

Reactions:— The reactions characteristic of albumose according 
to Munk are as follows: 

1. Not precipitated by heat. 

2. Careful addition of cold nitric acid produces a precipitate 
which dissolves with a yellow color on boiling, to reappear again 
on cooling. 

3. Addition of acetic acid and double the volume of a concen- 
trated sodium chloride solution, gives in the cold a cloudiness or 
precipitate which clears on boiling to reappear on cooling. 

4. The ferrocyanic test produces a cloudiness or complete pre- 
cipitation. 

5. Saturation with neutral ammonium sulphate precipitates 
them. 



196 URINARY ANALYSIS. 

6. Addition of tannic and acetic acids, or phospho-tungstic acid 
solution, produces a cloudiness or precipitate. 

7. The biuret reaction is obtained when alburnoses are present, 
after removal of coagulable proteids by boiling with a little acetic 
acid. 

Detection in urine: — The above reactions do not permit us to 
recognize small amounts of albumoses in urine either because they 
are not sufficiently delicate or else because they are characteristic 
of other albumins. Since in nearly all cases albumin or mucin or 
both are present, together with albumoses, the following methods 
must be tried. 

1. When the albumoses are present in considerable quantity, 
they may be readily detected by filtering the hot solution de- 
scribed in reaction 2 above. Albumoses separate out in the fil- 
trate on cooling. Or the hot filtrate will respond to the biuret 
test. Or, boiled with Millon's reagent, a red color is obtained. 

2. If the biuret test is obtained after removal of coagulable 
proteids: test the filtrate for albumoses by first, nitric acid and 
heat (note order), second, acetic acid and potassium ferrocyanide; 
third, saturation with common salt and addition of a drop or two 
of nitric acid. In the latter test, the precipitate resulting is espe- 
cially sensitive to heat, disappearing quickly on warming, reap- 
pearing on cooling. 

3. For the detection of one part albumose or peptone in 50,000 
parts of urine, M. L. Harris of Chicago, recommends the following: 

The urine must first be freed from the last trace of all coagul- 
able albuminoids before testing for albumose or peptone. 

This is accomplished as follows: 

To 20 c.c. of acid urine* in a test-tube are added six or eight 
drops of a saturated solution of salicyl-sulphonic acid (sulpho-sali- 
cylic acid) in distilled water, and 1 gm. of lead chloride. Shake 
well and boil about thirty seconds. Cool by shaking in running 
water from the cold water tap. 

Filter through ordinary clean, white, filter paper until the urine 
is clear. Now add a few drops of a clear saturated solution of 
sodium sulphate in distilled water, in order to precipitate what 
lead is held in solution; raise to the boiling point, and cool under 
the cold water tap as before. 

Filter again until clear. We should now nave a perfectly clear 
urine, absolutely free of every trace of coagulable albuminoids, 
including nucleo-albumin, in which we may search for albumose 
or peptone. This clear filtrate is divided into three equal portions 
and placed in test tubes, one of which is kept for comparison, the 
other two for further analysis 

To one of these are now added three or four drops of a saturated 
solution of salicyl-sulphotungstate of sodium in distilled water, f 



♦The urine must be fresh. If it must stand several hours before it can 
be examined, it should be preserved from the growth of bacteria in it by 
the addition of some antiseptic, preferably a few drops of formalin, which 
will keep it several days, aud does n >t interfere with subsequent tests. 

t Salicyl-sulphotungstate of sodium isprepiredas follows: To a boiling 
saturated solution of tunestate of sod um in distilled water salicyl-sul- 
phonic (sulpho-salicylic) acid is gradually added, under constant stirring, 
until the solution no longer turns red litmus blue; or in other words until 
the alkaline tungstate of sodium is completely neutralized. Upon cooling 
the salicyl-sulphotungstate of Sodium crystallizes. A solution is now made 
of this in cold distilled water and filtered. A perfectly clear colorless fluid 
results. 



PROTEIDS IN THE URINE. 197 

If albumose or peptone be present a cloudiness will appear, 
varying in degree according to the amount of these proteids 
present. 

As the amount of albumose present is often very minute, it may 
be necessary to compare the tube with the control tube in order 
to detect the cloudiness. 

The cloudiness disappears entirely on gently heating the test- 
tube, to reappear on cooling. 

In the third tube the test is varied by allowing about 5 c.c. of a 
dilute solution of the salicyl-sulphotungstate of sodium, made by 
adding about ten drops of the strong solution to 5 c.c. of distilled 
water, to flow very gently down the side of the tube so as to rest 
on the urine as a separate layer. 

This should be very carefully done that the line of contact will 
be sharp and clear-cut, not diffuse. A cloudy line appears at the 
point of contact of the two liquids, if albumose or peptone be 
present. 

When the amount present is very small, it may take two or 
three minutes for the line to develop and show best, the two 
liquids being clear, when held in front of a dark background. 

As before stated, this test is extremely delicate, one part in 
50,000 being readily detected; it is simple and can be easily applied 
in fifteen to twenty minutes. 

Owing to the delicacy of the reactions it is necessary that all 
test-tubes be absolutely clean and the test solutions perfectly clear, 
otherwise a slight reaction may be easily overlooked. 

The sodium sulphate solution must be added in slight excess in 
order to insure precipitation of all the lead, as any lead left in 
solution would be precipitated by the salicyl-sulphotungstate of 
sodium, and thus interfere with the test. This would be easily 
recognized, as the cloudiness in that case would not disappear on 
heating, but become more marked. The boiling during the appli- 
cation of the test, while not absolutely necessary, facilitates the 
reactions, and should always be done, the cooling, after boiling 
and before filtering, must never be omitted. 

3. Salkowski's modification of Hofmeister's test for what was 
formerly called peptone is as follows: Albumin is first removed by 
boiling and filtering (and testing of nitrate with acetic acid and 
potassium ferrocyanide to see that the urine is sufficiently acid; if 
albumin is found in the filtrate, acidulate the urine, drop by drop 
with 30 per cent acetic acid, boiling after each drop, filtering and 
testing with ferrocyanide). Fifty c.c. of the albumin-free urine 
are acidified in a beaker with 5 c.c. of hydrochloric acid and pre- 
cipitated with phospho-tungstic acid, the mixture being heated 
over the free flame when, in a few minutes, the precipitate will form 
a resinous mass, which closely adheres to the bottom of the vessel. 
The supernatant fluid is decanted off, and the mass at the bottom, 
which now becomes granular, washed twice with distilled water, 
which is likewise removed by decantation. The precipitate is 
then covered with about 8 c.c. of distilled water and treated with 
0.5 c.c. of a sodium hydrate solution (specific gravity 1 .16), Upon 
shaking the beaker the mass will dissolve, the solution assuming 
a dark blue color. This is heated on the free llame until the blue 
color turns to a dirty greenish-yellow. The solution ac the same 
time becomes turbid but, at times, may turn yellow and remain 
clear. This decoloration may be hastened by the further addition 
of a few drops of sodium hydrate bolution. As soon as this point 



198 URINARY ANALYSIS. 

has been reached, some of the liquid is placed in a test-tube, 
allowed to cool and then treated with a very dilute solution of 
copper sulphate (1 to 2 per cent), drop by drop, when, in the pres- 
ence of what were formerly called peptones, the solution assumes 
a bright red color, which may be brought out still more strongly 
if the specimen is now filtered. With this method which occupies 
only about five minutes, 0.015 gram of peptone pro 100 c.c. of 
urine may be demonstrated without difficulty. The quantity of 
urine used is so small that mucin niay be disregarded. 

Clinical significance of albumosuria: — Modern 
observers have agreed that true peptone has never as 
yet been found in urine. The products heretofore 
considered peptones by Hofmeister and others were 
not peptones at all, but albumoses. Hence the term 
albumosuria must be substituted for the term pepto- 
nuria, and the entire subject re-investigated. Harris's 
conclusions from many hundred examinations of urine 
are as follows : 

As the albumose is due to the digestive action of 
invading microbes on the albumins of the fluids and 
tissues of the body, its presence in the urine simply 
indicates that we have to do with an infective condi- 
tion in a state of more or less activity A word or 
two, however, in regard to the question of so-called 
peptonuria and the presence of suppuration within the 
body. 

The digesting or peptonizing power of the ordinary 
pus microbes is usually quite active, and, whenever 
suppuration is taking place anywhere within the body, 
albumose is always present in the urine. 

This albumosuria, however, can only be held indica- 
tive of suppuration when all other infective conditions 
can be excluded. The question may be stated thus : 
Given a patient with a probable circumscribed inflam- 
matory condition in which the infective diseases can 
be excluded, the presence of albumose in the urine is 
quite positive evidence that the condition is inflamma- 
tory ', and that suppuration has taken place. 

1. True peptone being very rarely, if ever found in 
the urine, the term peptonuria should be substituted 
by the term albumosuria. 

2. The albumoses are produced by the digestive or 



PROTEIDS IN THE URINE. 199 

peptonizing action of microbes on the albumins of the 
body. 

3. This digestive action is one common to all forms 
of living organisms. 

4. The albumoses are produced in quantities much 
in excess of what are appropriated by the microbes 
for their growth and development. 

5. The albumoses being readily diffusible the excess 
in production is quickly absorbed by the blood, where 
being toxic and thus acting as foreign bodies they are 
eliminated by the kidneys and appear in the urine. 

6. Albumosuria may be present in any condition or 
disease due to the action of micro-organisms within 
the body, and is thus simply indicative of an infective 
condition. 

According to Harris, products corresponding to the 
class, albumose or proteose, are found in the following 
conditions : 

All kinds of suppurative conditions, acute and 
chronic, such as pelvic abscesses, appendicular ab- 
scesses, peritonitis, suppurative lymphadenitis, subcu- 
taneous suppuration, osteomyelitis, etc., and in the 
following infective diseases which he has had an 
opportunity to examine : 

Acute croupous pneumonia, la grippe, phthisis pul- 
monalis, diphtheria, typhoid fever, syphilis, one case 
secondary stage, and one case of septicaemia of un- 
known origin. 

Albumosuria very frequently accompanies albumin- 
uria, in which case the condition is called mixed albu- 
minuria. Albumosuria may alternate with albumin- 
uria and precede as well as follow the latter, so that 
in any case in which albumoses are demonstrable in 
the urine, the appearance of albumin should be 
expected. 

Dr. Sidney Martin found in a case of empyema that 
the amount of albumose in the urine varied inversely 
with the purulent discharge. 

Drs. Dickinson and Fyffe noticed a complete disap- 
pearance of albumose from the urine when pus was 
evacuated. 



200 URINARY ANALYSIS. 

Alburaose is not found in the urine in many cases 
where there is a large collection of pus in the abdomen 
or in an hepatic abscess ; doubtless due to thickness of 
the membrane surrounding the pus and interfering 
with its absorption. 

In a case of acute bronchitis with pleural pain a 
peculiar albumose has been found in the urine most 
closely related to protomyosinose (a primary product 
of the digestion of myosin, the latter a native proteid 
of the globulin class, whose coagulation in muscle after 
death causes rigor mortis). 

In most virulent and fatal cases of pneumonia, with 
extensive hepatization of the lung, albumoses are 
absent, and their appearance is possibly a favorable 
indication in this disease. 

In many cases, however, of suppuration in the chest 
cavity with albumoses in the urine the noticeable 
features are severe character during primary fever, 
high mortality, and occasional serious sequelae apart 
from development of empyema. 

Finally it is said by Dr. Saundby (the Interna- 
tional Annual for 1897) that albumose is found by 
delicate tests in the urine of the perfectly healthy. 

NOTES ON PEPTONURIA, FORMERLY SO-CALLED. 

(a) According to Maixner peptone is always present in urine 
when pus is forming, the peptone constituent of leucocytes being 
absorbed into the circulation, whence it is eliminated by the 
kidneys. 

(6) Again, extensive destruction of the corpuscular elements of 
the blood is a cause of peptonuria. Hence we find peptonuria in 
(a) the declining stages of pneumonia, in purulent pleuritis, sup- 
purating tuberculosis, chronic bronchial catarrh, psoas abscess, 
purulent meningitis, acute articular rheumatism, and (b) acute 
infectious diseases and toxic conditions of the blood: — phosphorus 
poisoning, croupous pneumonia, typhoid-fever, small-pox, scarlet- 
fever, mumps, erysipelas, empyema, visceral cancer, especially of 
liver and intestines, catarrhal jaundice and apoplexy. 

(c) Peptonuria (used in the former sense of the word) is almost 
invariably associated with cancer of the liver. 

(d) Peptone is said, to be a normal constituent of urine in the 
puerperal state. 

(e) Ulcerative changes in the lungs being excluded, peptonuria 
is significant of epidemic cerebrospinal meningitis as distin- 
guished from tubercular. (J'aksch.) 

(/) Peptonuria, it is said, distinguishes septicaemia from latent 
disseminated sarcoma. 






PROTEIDS IN THE URINE. 201 

(a) Peptonuria occurs in ulceration of the intestines, and when 
peptone is injected into the blood. 

It seems quite probable that many of these condi- 
tions of so-called peptonuria maybe found to be 
accompanied by presence of albumose 

HAEMOGLOBIN. 

Haemoglobin, the red pigment of the blood, contains 
iron, and" gives the proteid reaction. Hemoglobin- 
uria occurs whenever the liver is for any reason, unable 
to transform into bilirubin all the blood-coloring mat- 
ter set free by destruction of red blood corpuscles. 
In such a case the urine contains few red corpuscles or 
none at all, but the coloring matter of the blood may 
be recognized by the following: 

! Tests ■—Guaiaoum test: -Mix equal parts of old 
oil 'of turpentine, which has become ozonized by 
exposure to the air and light, and tincture of guaiaoum 
which has been kept in a dark-glass bottle, and then 
float carefully on the surface of the mixture an equal 
volume of the urine to be tested If haemoglobin be 
present, a bluish-green ring, becoming a beautiful 
blue appears when the two liquids meet, and, on 
shaking the mixture becomes blue. If the urine con- 
tain pus, the latter will color the guaiacum alone with- 
out the turpentine and the blue color will disappear, 
when heated to the boiling point which is not the 
case when the blue color is due to haemoglobin. The 
urine tested should be fresh or made faintly acid. 

2 Examine the urine spectroscopicauy as follows : 
Render' feebly acid by means of acetic acid, and place 
before the open slit of the spectroscope m a test-tube, 
breaker or similar vessel, when the two bands of oxy- 
hemoglobin (arterial blood), will be seen either at 
once or upon carefully diluting with distilled water 
If ammonium sulphide be now added, the spectrum of 
reduced hemoglobin (venous blood) will be obtained. 
More commonly, however, the spectrum of raethae- 
mo.'lobin (a mixture of albumin, haemoglobin, and 
hematin), is seen in cases of haeraoglobmuria. 

26 



202 URINARY ANALYSIS. 

3. Heller's test: — Boil urine to which solution of 
potassium hydroxide has been previously added to pre- 
cipitate phosphates. The latter will present a bright- 
red color, if haemoglobin is present. If it is difficult 
to appreciate the color, filter, and dissolve in acetic 
acid, when, if blood pigment be present, the solution 
becomes red, and the color vanishes gradually on 
exposure to the air. This test is quite as delicate as 
the guaiacum one. 

Clinical Significance: — 

1. Hemoglobinuria is most frequently observed 
after poisoning by potassium chlorate, arseniuretted 
hydrogen, sulphuretted hydrogen, creasote, pyrogallic 
acid, naphthol, hydrochloric acid, tincture of iodine, 
carbolic acid, carbon monoxide, phosphorus, and also 
by morels (Helvella esculenta). 

2. Hemoglobinuria follows injection into the blood 
of solvents of the corpuscles as glycerin, solutions 
of bile-salts, or distilled water; also after transfusion 
of the blood of animals into man. 

3. Hemoglobinuria may occur in the course of any 
one of the specific infectious diseases, as scarlatina, 
icterus gravis, variola hemorrhagica, yellow fever, 
typhoid, typhus, and probably syphilis. 

4. It occurs in pyemia, scurvy, fat-embolism, some 
cases of jaundice, after extensive burns, occasionally 
in Raynaud's disease, and in leukemia complicated by 
icterus. 

5. From unknown causes as an epidemic among new 
born. 

6. In the so-called paroxysmal hemoglobinuria the 
attacks are frequently preceded by chills and fever 
closely simulating malarial lever. It must be, how- 
ever, distinguished from malarial hematuria. Simon 
and others doubt the existence of malarial hemoglobi- 
nuria while malarial hematuria is well-known. 

Note:— Hemoglobinuria is the voiding of urine containing the 
coloring matter of blood, but few or no corpuscles; hematuria is 
the voiding of urine containing both the coloring matter and 
corpuscles. 






PROTEIDS IN THE URINE. 203 

FIBRIN. 

Fibrin in the urine may be either in solution or coagulated. In 
the former casecoagula separate or standing, covering the bottom 
of the glass or changing the entire bulk of urine into a gelatinous 
looking mass. In the coagulated state, fibrin is observed at times 
in the form of blood-coagula in hematuria. 

Test: — Wash the clots thoroughly with water and dissolve by 
boiling in a 1 per cent solution of sodium hydrate or a five per 
cent solution of hydrochloric acid. On cooling, the solution is 
tested as for serum-albumin. 

Significance: — Colorless coagulaof fibrin are seen only in cases 
of chyluria or in diphtheritic inflammation of the urinary pass- 
ages. In most cases of hsematuria with clots, the fibrin comes 
from the kidneys, although it is often associated with haemor- 
rhages into the urinary tract, and is seen frequently in cases of 
villous tumors of the bladder. 



NTJCLEO- ALBUMIN. 

The term nucleo- albumin is given to the body occas- 
ionally present in urine, which is precipitated by acetic 
acid, and is insoluble in excess of this reagent, though 
soluble in nitric acid. It has been also called mucin, 
a mucinous bod}^. and a globulin, and the term muci- 
nuria has been applied to the condition in which urine 
contains it. Much contradiction exists in regard to 
the nature of it. 

Tests: — The carefulty filtered urine is treated in a 
test-tube, drop by drop, with an excess of concentrated 
acetic acid, when the occurrence of a turbidity will 
indicate presence of nucleo-albumin. Kemove albu- 
min first by simple boiling, and dilute the urine if 
necessary before testing. 

Albumin and nucleo-albumin: — E. E. Smith's 
method of distinguishing albumin from nucleo-albu- 
min is as follows : About an inch of clear filtered 
urine in a test-tube is heated to boiling, after which 
two or three drops of ten per cent nitric acid are added. 
If, after a few moments, there is no reaction for albu- 
min, the contents of the tube are again boiled, and 
about ten drops of the nitric acid further added, and 
the tube set aside. 

A quarter of an inch of a clear five per cent solu- 
tion of potassium ferrocyanide is placed in a test-tube, 
an equal volume of dilute acetic acid is added, and the 



204 URINARY ANALYSIS. 

whole poured into an inch of clear urine in another 
test-tube, the liquids being well mixed by pouring 
from one tube to the other several times. The test- 
tube is then set aside. A comparison tube is prepared 
as follows : An inch of the urine, clarified at the 
same time as that previously used, is placed in a test- 
tube, and two drops of dilute acetic acid are added. 
This tube is likewise set aside. 

If both tests react positively, either a trace of true 
albumin or of mucus is present, to decide which, it is 
necessary to observe the comparison tube, in which, if 
mucus is present, there will be some turbidity from the 
partial separation of nucleo-albumin. If the urine in 
the comparison tube remains perfectly clear, and the 
reactions with heat and with ferrocyanide present the 
appearance characteristic of the albumin tests, then it 
is safe to conclude that a mere trace of true albumin is 
present, but the appearance of even a slight cloudi- 
ness in the comparison tube is to be taken as evidence 
of the presence of mucus, to which then the delicate 
heat and the ferrocyanide tests are to be attributed. 
Since the separation of nucleo-albumin in the com- 
parison tube is only partial, it is evident that no com- 
parison can be made between the intensity of this 
reaction and the heat and the ferrocyanide reactions. 

The appearance characteristic of the heat and nitric- 
acid reaction with a trace of albumin is either the 
formation of a few flakes of coagulated albumin or the 
formation of a general turbidity which finally results 
in a fine flocculent separation, persisting when the 
solution is hot. The addition of one-third to one- half 
the volume of alcohol causes the flocculent appearance 
to become more pronounced, while any separated 
resinous substances, thymol, etc., pass into solution. 

When traces of true albumin are present, the ferro- 
cyanide test gives a finely flocculent appearance, while 
with nucleo-albumin a mere opacity is more common. 

Finally, it is to be remembered that albumin is to 
be considered absent from a urine till its presence is 
demonstrated by methods which admit of its distinc- 
tion from mucus. Undoubtedly the safest basis for 



PROTEIDS IN THE URINE. 205 

interpretation, except perhaps in the hand of the 
skilled analyst, is the requirement of three reactions. 
(The two above, and Heller's test) ignoring such traces 
as fail to respond to Heller's test. 

Bladder mucus does not contain mucin but a proteid 
probably identical with nucleo-albumin, and only 
incompletely precipitated by acetic acid. To remove 
it from urine, (X E. Simon recommends treating the 
urine with neutral acetate of lead, carefully avoiding 
excess. 

Significance: — Sarzin and Senator were unable to 
find nucleo-albumin in 200 urines from almost the 
entire list of hospital diseases. 

C. E. Simon insists that an elimination of it from 
the blood through the kidneys does not exist, and that, 
when found, it is due to improper methods and refer- 
able to disintegrating epithelia. 

Reissner, Obermeyer, and others claim to find it in 
various diseases. Reissner says it may precede albu- 
min and continue longer than the latter. Obermeyer 
finds it in icteric urine and in that of other diseases. 

Purdy says that in catarrhal inflammations of the 
urinary passages, mucin is much increased and may 
form ropy, tenacious strings, or settle in jelly-like 
mass. 

Some author's allude to nucleo-albumin from bile, and it is said 
that the mucin of bile differs from that of mucous membrane in 
not being completely separated by acetic acid. The reader is 
referred to Fraser's Notes for January, 1895. and to Dr. Landon 
Carter Gray's well-known paper in the American Journal of 
Medical Sciences, for October, 1894, in which differential testing 
is described. It should be noted, however, that clarification of the 
urine by powdered French chalk, filtering through talc, etc., has 
recently been said to remove albumin as well as mucin from the 
urine. 

Almost unsurmountable difficulties seem to beset us in the study 
of the albuminoid of mucus, and great difference of opinion 
exists as to its origin, nature, and properties. 

HISTON. 

This albuminous body was first found by Kossel in the red-blood 
corpuscles of the goose. It has been shown to exist in the leuco- 
cytes of human blood, in combination with the acid leuko-uuclein, 
the so-called nucleo-histon of Lilienfeld. It has been found in 
the urine in a case of leukaemia by Kolisch and Burion as follows: 
Albumin being removed, the urine was precipitated with 94 per 



206 URINARY ANALYSIS. 

cent alcohol, the precipitate washed with hot alcohol and dis- 
solved in boiling water. On cooling, the solution was acidified 
with hydrochloric acid and let stand several hours, filtered, and 
precipitated with ammonia. Histon, if present, is now thrown 
down in addition to certain mineral constituents. The precipitate 
is collected on a small filter, and washed with ammoniacal water 
until the washings no longer give the biuret reaction . It is then 
dissolved in dilute acetic acid, and the solution tested with the 
biuret test; if this yields a positive result, and, if coagulation 
occurs, on application of heat, the coagulum being soluble in 
mineral acids, the presence of histon may be inferred. 



SUGAR IN THE URINE. 207 



CHAPTEK XXXIII. 



SUGAR- IN THE URINE. 

Introductory. The sugar found in the urine in the 
conditions known as glycosuria and diabetes mellitus 
is not cane sugar, as many medical students think, but 
a substance very like grape-sugar, which probably 
occurs in minute quantities in normal urine, and in 
greatly increased quantity in diabetes mellitus. 

Synonyms: — Sugar : — German, Zucker ; French, 
Sucre. Grape-sugar, dextrose, glucose : — German, 
Traubenzucker ; Glycose, Dextrose, Ilarnzucker \ 
French, Glycose, Dextrose. 

Chemical constitution: — C d H i2 6 , a carbohydrate 
containing 6 atoms of carbon ; is one of the class of 
monosaccharides, group hexoses, sub-group aldoses. 

Reactions: 

1. Absorbs oxygen when heated with strong alkali solution, 
giving rise to characteristic color and odor. 

2. Heated with alkaline solution of cupric salts, reduces them 
with (red) precipitate of cuprous oxide. 

3. Reduces bismuth subnitrate to the metallic condition, when 
heated with it in presence of an alkaline solution. 

4. Warmed with a solution of phenylhydrazin hydrochloride in 
water, to which a little sodium acetate is added, forms a yellow 
crystalline precipitate of phenylglucosazon. 

5 Fermented by yeast splits into alcohol, carbon dioxide, and 
a number of other substances. 

6. Boiled in faintly alkaline solution colored blue by indigo 
exhibits a beautiful color reaction. 

7. Gives color reactions with various substances, as with alpha- 
naphthol and thymol in presence of sulphuric acid. 

The method of application of these tests will be shown further 
on. 

A. CLINICAL TEST FOR SUGAR IN URINE. 

One of the most satisfactory and reliable tests for 
sugar, if performed with care, is that made by use of 
Professor Walter Haines' test-liquid. 

Haines' test-liquid made by the metric system: 

2 grams of copper sulphate, 15 c.c. of water and 



2J8 URINARY ANALYSIS. 

glycerine each, and 150 c.c. of liquor potass®. Use 
3.75 c.c. of the liquid in making the test. 

Haines' sugar-test liquid (American measures) : — 
A permanent, transparent, dark-blue solution contain- 
ing cupric sulphate, and potassic hydroxide, dissolved 
in glycerine and water. It is made as follows:* 
Make a perfect solution of cupric sulphate ("free from 
iron,") 30 grains, in one-half fluidounce of distilled 
water: to this add one-half fluidounce of pure glycer- 
ine; mix thoroughly, and add liquor potassas five 
fluidounces. Owing to the fact that even the best 
grade of cupric sulphate contains traces of the ferric 
salt, Haines' test-liquid will usually deposit, on stand- 
ing, a slight reddish sediment. To avoid mistakes it 
is wise to let the solution settle before it is used and 
then decant from the sediment. 

Testing the quality of Haines' liquid : — In order 
to be sure that the solution has been properly made, 
proceed as follows : Take one fluidrachm of the liq- 
uid (which quantity will fill a five-inch test-tube to the 
depth of about one inch), and boil it in a clean test- 
tube for thirty seconds or more. Now let it cool. 
Neither before cooling nor after should it show any 
change of color. Compare it after boiling with a 
fluidrachm which has not been boiled. The two should 
look exactly alike. Now take the second fluidrachm 
which has not yet been boiled and bring it to .the boil- 
ing point, also in a clean test-tube. Add a drop of 
normal urine to it and bring to the boiling point again ; 
repeat the process adding drop by drop till eight drops 
of urine have been added Then boil thirty seconds. 
Now let cool and see that no change in the color takes 
place, though perhaps whitish flocks of phosphates can 
be seen, suspended in the liquid, which in a short 
time settle, forming a dirty >-wt kite sediment in the tube. 
Compare with a third fluidrachm of the liquid which 
has not been boiled and the only difference seen will 
be due to the deposit of phosphates. There should be 

*See Writer's "Diseases of the Kidneys" 2 Ed. p. 369. 



SUGAR IN THE URINE. 209 

no reddish, greenish, nor yellowish tinge to the liquid 
after it is ooiled with normal urine. 

Detection of sugar with Haines' test-liquid: — 
Having ascertained that the test-liquid is of good 
quality take a fluidrachm of it, boil it, and add one 
drop of the suspected urine to it. If much sugar is 
present in the urine, a change at once takes place ; 
the whole liquid becomes turbid and changes color to 
yellow, reddish-yellow, or brown-yellow. If no such 
change takes place after adding a drop of urine, add 
another drop and bring to a boil again, "and so on 
until the turbidity and discoloration are seen ; urine 
which contains but a moderate quantity of sugar may 
require four drops to be added, boiling after each drop. 
Or it may be necessary in case but a small quantity of 
sugar be present, to add eight drops of urine, boiling 
after each drop, and after the eight drops are added 
to boil for thirty seconds, before any change be seen. 
If, however, no change is seen even then, let the tube 
cool, when, provided but a small quantity of sugar be 
present, the liquid becomes greenish and turbid. 
But if no sugar is present, the brilliant blue transpar- 
ency is unaffected on cooling. 

Precautions: 

1. The test depends on the reduction of the cupric sulphate to 
cuprous oxide. Normal urine has a slight reducing power on the 
solution in case of prolonged boiling, therefore do not boil too 
long, thirty seconds being enough. 

2. Do not forget to set the tube aside after the test has been 
made and let it cool. A small quantity of sugar causes a turbidity 
only on cooling. A dirty test-tube is more often responsible for 
the change on cooling. 

3. Do not use a sample of the liquid which contains a reddish 
sediment, lest the latter appear in the test-tube, and be mistaken 
for a reduction. Decant or filter the liquid before using. 

4. Do not mistake the whitish flocks of phosphates precipitated 
in all urine, by this test, for sugar. 

5. Do not use a dirty test-tube, since Haines' liquid is exceed- 
ingly sensitive to the presence of numerous organic substances. 
The test-tube must be thoroughly cleaned beforehand. 

6. Do not use more than 8 or 10 drops of urine; a larger quan- 
tity of even normal urine may cause reduction. 

7. Do not add any chemicals whatever before or after the test. 

8. Use a clamp for holding the test-tube and not too great heat. 
An alcohol lamp is better than a Bunsen burner, unless the latter 
be turned low. 

27 



210 URINARY ANALYSIS. 

9. Point the mouth of the test-tube away from everybody when 
boiling, as the liquid sometimes "bumps.'' 

NOTES. 

1 . Haines' test-liquid is affected by numerous organic substances 
even in small quantities: For example, 1 or 2 drops of 20 per cent 
acetic acid make it turbid and green on cooling; 2 drops of carbolic 
acid cause a precipitate, but the blue color is not entirely lost. 
The writer has found that a number of substances, left as samples 
by enterprising agents of various chemical manufacturers, either 
give copious characteristic precipitates, as in case of Panopeptone, 
Forbes' diastase, Sabalol balsam, or else a precipitate of some sort 
not typical, as in the case of a "non-saccharine solution of the 
hypophosphites." which gave a grayish- white precipitate, without 
changing the blue of the liquid. Chloral hydrate, chloroform, and 
sulfonal have a reducing power on the cupric tests, a fact which 
must be borne in mind, when these substances are added to urine 
for antiseptic purposes, or when taken internally. 

2. The question then conies up as to the possibility of a reaction 
with Haines' test, when such substances are taken internally. So 
far as grape-sugar itself goes, the writer has proved in his own 
case that copious ingestion of solutions rich in glucose fails to 
render the urine saccharine, that is, no reaction with Haines' test 
has been obtained. 

3. On the other hand there are those persons who, though free 
from diabetes, void, when taking strongly saccharine solutions, 
glucose in the urine. The writer published in the Hahnemannian 
of 1892 his observations on the reaction with Haines' test of the 
urine of a certain person, who was drinking freely of champagne, 
rich in glucose. It is thought by v. Noorden that such a condi- 
tion is significant of a tendency to diabetes, and he tests the urine 
of his patients after administering 100 grams of grape-sugar to 
them. 

4. In consequence of the above the writer is in the habit, when 
testing urine for sugar, to specify that the patient shall eat freely 
of saccharine articles and to test the urine of each micturition 
separately. It has been found that the urine voided in the after- 
noon, about 3 or 4. o'clock, is most likely to affect Haines' solution. 
"When a marked reaction occurs at this time, the writer subjects 
the urine of this particular hour to fermentation so as to avoid 
error from possible presence of various organic substances includ- 
ing those of the urine, as glycuronic acid. 

It goes without saying that all glasses used shall be rigorously 
cleaned, before any conclusions as to presence of a trace of sugar 
can be arrived at. 

5. Some curious facts as to this afternoon reaction with Haines' 
liquid have come under the writer's observation: One patient 
would manifest it in the urine voided after eating bananas; 
another whenever he drank ordinary tap beer, but not when he 
drank bottled imported beer. 

6. In several cases where this doubtful reaction has been found, 
prohibition of saccharine articles of food together with reduction 
in starchy foods has been followed by an improvement in the gen- 
eral health of the patient and disappearance of the reaction. 



SUGAR IN THE URINE. 211 



ADVANTAGES OF THE HAINES' TEST-LIQUID. 

1. The solution is stable being known to keep fifteen years when 
properly made from pure materials. The writer keeps it in a 
dark place. 

2. By adding the urine, drop by drop, the chances of reduction 
by the other substances than sugar are lessened. 

3. An idea as to the amount of sugar present may be had 
approximately as follows: — If one or two drops of urine give an 
immediate yellow or red precipitate, sugar is abundant, 4 per cent 
or more; if several drops are necessary to produce the yellow pre- 
cipitate, sugar is moderately abundant; if eight drops of urine 
are required before any change occurs, sugar is in small amount; 
if no change occurs until after cooling mere tracps are present. 
It is understood, however, that the tube is not allowed to cool 
while the urine is being added. 






212 URINARY ANALYSIS. 



CHAPTER XXXIV. 



USUAL LIFE INSURANCE TESTS FOR SUGAR 

One of the most commonly used test solutions is 
Fehling's, which is made as follows : — (1) Dissolve 
69.28 grams of pure recrystallized copper sulphate 
in enough distilled water to make 'one liter; (2) Dis- 
solve 100 grams of sodium hydroxide, "by alcohol," 
in sticks, in 500 c.c. of distilled water. Heat to boil- 
ing, and add gradually 350 grams of pure recrystal- 
lized Rochelle salt. Stir until all is dissolved. Allow 
the solution to stand 24 hours in a covered vessel, then 
filter through asbestos into a liter flask, and add water 
to make 1 liter. Keep each of these solutions in a 
separate bottle. There are several methods of apply- 
ing the test : 

Method I : — Mix equal parts of. the two solutions 
described above using about a fluidrachm (4 c.c.) of 
each. Pour 4 c.c. (one fluidrachm) of the blue solu- 
tion thus made into a test-tube and test its stability 
by boiling. If no change occurs on boiling, add 3 or 
4 drops of the urine to be tested and boil again. If 
much sugar be present, after a short time there results 
a dense, opaque, yellow color, and a yellow-red preci- 
pitate soon settles to the bottom of the tube. In case 
of no change of color with 3 or 4 drops, continue add- 
ing urine until an amount equal to the amount of the 
solution has been added ; that is, if the amount of 
solution used is 4 c.c, add in all 4 c.c. of urine but 
no more. If no precipitate or change occurs, sugar is 
absent. 

Method II. — Pour 4 c.c. of the solution into a 
test-tube, and add an equal amount of water. Boil 
and the solution must remain clear. Then add |- c.c. 
of urine and boil, when, if sugar is present in amount 
greater than one-tenth of one per cent, the yellow 



SUGAR IN THE URINE. 213 

color appears. If not, add more urine and boil again, 
and so on until an equal amount of urine has been 
added. 

Method III : — Mix equal parts of the two solutions, 
dilute with four times as much water, boil, add a 
small amount of urine and warm, not boil. 

PRECAUTIONS. 

1. it is important not to mix the two solutions until just before 
the test is made, as the blue liquid formed does not keep well. 

2. Even when the solutions are kept separately, it is said that 
the tartrate used is likely to decompose, racemic acid being 
formed, which reduces cupric salts. 

3. A greenish flocculent precipitate always occuring in greater 
or less quantity when the urine is added, is due to precipitated 
phosphates. 

4. A clear dark green solution sometimes formed, when the 
urine is heated with Fehling's solution, is not significant of sugar, 
but is due to partial reduction by normal constituents of the urine 
as uric acid, kreatinin, etc. A colorless mixture is indicative of 
the same partial reduction. Drugs taken internally may cause 
the same reaction. 

5. If, however, with this change of color a red precipitate takes 
place, the urine must be tested with the bismuth test or by fer- 
mentation. Occasionally uric acid is so abundant as not only to 
discharge the color of the mixture, but also to cause precipitation 
of the red oxide of copper, and hence cause doubt. 

6. The same precautions in regard to cleansing the tubes are 
necessary as in case of Haines' liquid. 

7. It is also advised to remove albumin before applying the test. 
This is done by boiling and filtering. 

8. Some companies recommend their examiners to neutralize 
the urine before applying Fehling's test. 

9. Morphine, tannin, salicylic acid, salol, cubebs, copaiba, rhu- 
barb, senna, sulfonal and antipyrin reduce Fehling's solution. 
Internal administration of chloral, camphor, etc , produce gly- 
curonic acid in the urine, which affects Fehling's test. Glycosuric 
acid gives a positive reaction, but is rare in urine. 

10. When the quantity of sugar is small and there is a fear 
that the reduction of Fehling's solution has resulted from uric 
acid or from kreatinin, some advise to filter the urine first three 
times through animal charcoal. If Pavy's ammoniated cupric 
test is used instead of Fehling's, a larger quantity must be 
employed and the urine added to the depth of two inches in the 
tube. Boil the upper portion of the mixture, which loses its blue 
color, if sugar be present. Fermentation over mercury is prob- 
ably safest in such cases. 

NOTES. 

1. Fehling's solution made as above is used for quantitative 
determinations. 

2. Fehling's solution is said to detect even traces of sugar, and 
to be more delicate than Trommer's test. 



214 URINARY ANALYSIS. 

3. A very convenient arrangement for keeping the two solutions 
separately, is described by J. H. Long as follows: — Two bottles, each 
holding about 200 c.c, are fitted with perforated rubber stoppers. 
Through the opening in each stopper the stem of a 2 c.c. pipette 
with very short tip is passed, and left in such a position that, when 
the bottles are half filled, the bulbs and stems to the mark will be 
covered with the liquid. One bottle contains the standard copper 
sulphate solution, the other the mixture of alkali and tartrate 
solution. The rubber stoppers should be covered with vaseline so 
that they will permit the pipette stems to slide easily in the per- 
forations, and also close the bottles perfectly. When the stoppers 
are inserted, the pipettes should stand full to the mark, ready for 
use. 

On withdrawing the stoppers with forefinger closing the pip- 
ettes, exactly 2 c.c. of each liquid can be taken out without delay, 
and on mixing in a test-tube yield the Fehling solution, fresh 
and ready for use, directly, or after dilution with distilled water, 
as thought necessary. As the solutions are used the pipette stems 
are pushed farther through the stoppers so as to leave the marks 
always at the surface of the liquids. The solutions may be kept 
in this manner for years, and their use is not attended with any 
inconvenience. The open ends of the pipette stems should be 
kept closed with small rubber caps, or a bit of soft paraffin wax. 

THE BISMUTH TEST. 

The bismuth test is used for the reason that bismuth salts are 
not reduced by uric acid. 

Principle:— Bismuth oxide in alkaline solution is reduced by 
glucose, a precipitate of lower oxides of bismuth taking place. 

Method of Preparation: — Nylander's modification of Almen's 
test is prepared by dissolving 4 grams (62 grains) of potassium 
sodium tartrate in 100 grams of an 8 per cent solution of caustic 
soda, warming the fluid and adding as much subnitrate of bis- 
muth as will remain in solution, namely, about 2 grams Filter, 
on cooling, and keep in a colored glass bottle. 

Method of Application:— Add 1 c.c. of the bismuth solution to 
11 of the urine and boil for a few minutes. If sugar is present, 
the solution becomes first yellow, then yellowish-brown, and 
lastly nearly black, due to formation of lower oxides of bismuth. 

Chances for Error: — 

1. When abundance of albumin, pus, or blood is present, sul- 
phide of bismuth is precipitated, which is a black deposit similar 
to that caused by presence of sug ir. 

2. The reaction occurs in urines containing melanin or melano- 
gen. 

3. When the urine contains a large proportion of reducing sub- 
stances without sugar, the reaction occurs; but uric acid and 
kreatinin do not reduce the bismuth test. The substances which 
reduce the bismuth oxide are glycuronic acid combinations, and 
substances formed after use of kairin, rhubarb, eucalyptus tinc- 
ture, large doses of quinine, turpentine, and other drugs. 

4. Glyeosuric acid gives a blackish discoloration. 

5. In the presence of but very little sugar the solution is not 
black or dark brown but only deeper colored, and after some little 
time we see merely a dark or black edge on the upper layer of the 
phosphatic precipitate. 



SUGAR IN THE URINE. 215 

6. After standing for a time it is natural that a black deposit 
should be found in the tube, the supernatant liquid becoming 
clearer but still colored. 

7. It is said that urines containing less than 0.3 per cent of 
sugar do not react with Nylander's test. 

Since a small amount of albumin does not interfere with this 
test, it is easier to boil the urine and filter it before applying the 
bismuth test than to use Briicke's test, which requires some little 
time and skill for performing it. 

In the writer's opinion the cupric test and the bismuth tests are 
all that are necessary for life insurance purposes. 

THE FERMENTATION TEST. 

This test may be used to confirm the bismuth test. It should 
be performed as follows: — Fill three test-tubes each half full of 
mercury. To the first add the urine to be tested, to the second 
add water, and to the third add a 1 per cent solution of grape- 
sugar. Into each of the tubes drop a piece of compressed yeast, 
of the same size in each. Cover the mouth of each tube in turn 
with the thumb, invert over a small vessel of mercury, and set the 
whole aside for several hours. If sugar is present, the urine in 
the first tube should be displaced by the carbonic acid gas formed 
to a greater extent than in the second. If the yeast is active, the 
displacement in the third tube should be more noticeable than 
that in the second. 
Chances for Error: 

1. The urine, if not acid, should be made faintly acid by addi- 
tion of a little tartaric acid. 

2. Less than one per cent of sugar may not be detected, since 
the carbonic acid gas formed, is somewhat soluble in the urine. 
Remarks: 

The fermentation method may be used in conjunction with the 
bismuth test as follows: — When the bismuth test gives only a 
faint reduction, treat the acid urine with yeast whose activity has 
been tested by the solution known to contain sugar, and allow it 
to stand 24 to 48 hours in a warm place. Again test with the bis- 
muth test, and if the reaction now gives negative results, sugar 
was previously present But if the reaction continues to give 
positive results, other reducing bodies than sugar or perhaps sugar 
with other reducing bodies is present. 

CHEMICAL EXERCISE XV. 

A. 1. Make up a four per cent solution of glucose or 
grape-sugar and note the change which takes place 
when a single drop of this solution is added to 4 c.c. 
(one fluid rachm) of Haines' solution heated to boiling. 

2. Dilute the glucose solution with equal parts 
water, and add several drops successively to the 
Haines' solution heated to boiling. 

3. Dilute the glucose solution with two and four 
parts of water respectively, and add 8 drops of each 



216 URINARY ANALYSIS. 

to the boiling Haines' solution. If no change occurs 
in either case, let the tube cool and note change if any 

4. Dilute the glucose solution until no change occurs 
until after the tube cools. Note carefully the char- 
acter of the change. 

B. 1. For several successive exercises test urines 
containing different quantities of sugar with Haines' 
test. 

2. Kepeat the operation with Fehling's test. 

3. Eepeat the operation with the bismuth test. 



SUGAR IN THE URINE. 817 



CHAPTER XXXV. 



DELICATE TESTS FOR SUGAR. 

For clinical purposes the tests already given viz. 
preferably by Haines' test-liquid, or Fehling's, Almen's 
(Ny lander's), and the fermentation method are all 
sufficient. The remaining tests are, however, exceed- 
ingly delicate and hence will be included : — 

trommer's test. 

To about one fluidrachm (4 c.c.) of urine in a test-tube add 
enough cupric sulphate solution to make the urine light-green in 
color; then add an equal volume of liquor potassae. A blue pre- 
cipitate of hydrated cupric protoxide occurs at first, which, on 
shaking the tube, dissolves, forming a beautiful, clear, blue solu- 
tion. If allowed to stand half an hour or so, reduction gradually 
takes place, especially if much sugar be present, a yellow or yel- 
lowish-red precipitate of suboxide of copper being formed. If 
instead of letting stand half an hour gentle heat be applied, the 
test becomes more delicate and reduction occurs at once. The 
objections to the test are that, if it be not boiled it is not very 
sensitive, and when it is boiled, especially if long, other sub- 
stances than sugar may reduce the copper salt. (See notes in next 
C hapter). 

MODIFICATIONS OF FEHLING'S TEST. 

Boil 8 c.o. of urine with 5 c.c. of cupric sulphate solution of the 
strength used in Fehling's test. Let cool and add 1 to 2 c.c. of a 
saturated sodium acetate solution. Filter, add 5 c.c. of alkaline 
tartrate of the usual strength, and boil 15 to 20 seconds. The test, 
when hot, shows as little as one-quarter of one per cent of sugar 
and less still on cooling. (Allen's test). 

Another modification is to remove alkaloids by filtering through 
animal charcoal, make alkaline with mercuramin, and then any 
reduction of an alkaline copper tartrate solution is due to dextrose. 

THE PHENYLHYDRAZIN TEST. 

Phenylhydrazin, CeH 6 .NH — NH 2 is a derivative of hydrazin, 
NH 3 — NH,, formed by the replacement of a hydrogen atom by 
the aromatic radical phenyl, C 8 H 6 . Hydrazin or diamin, N 2 H 4 , 
is a substance in man}- ways resembling ammonia gas. Phenyl- 
hydrazin itself is a colorless oil of powerful reducing properties 
which forms crystallizable salts with acids, of which the hydro- 
chloride is used as a test for small quantities of sugar. 
28 



218 



UEINAR Y ANAL YSIS. 



Principle: — Phenylhydrazin has the property of forming with 
grape-sugar a highly characteristic crystalline compound known 
as phenylglncosazon. 

Methods of application: — There is difference of opinion as to 
how the phenylhydrazin test should be applied; one method is as 
follows: Treat 6 or 8 c.c. of urine with two points of-a-knifeful 
of phenyl hydrazin hydrochlorate and 3 parts of acetate of sodium 
and warm until the salts have been dissolved, a little water being 
added if necessary. Plunge the tube in boiling water for twenty 
to thirty minutes, and then suddenly plunge into cold water. If 
sugar be present in moderate amounts, a bright yellow crystalline 
deposit will at once be thrown down, partly adhering to the sides 
of the tube. Traces of sugar will be revealed by the presence of 
crystals of phenyl glucosazon, very delicate, bright yellow needles, 
singly or in bundles and sheaves, insoluble in water. Fig. 43. 




FlG. 48. Crystals of phenylglucosazon. 

Jolles uses the test by boiling the test-tube in a water bath for 
one hour, and then letting stand for 12 to 14 hours. The method 
by use of the water bath is generally given as follows: 

To 25 c.c. (6^ fluidrachms) of the urine to be tested add 1 gram 
(15 grains) of phenylhydrazin hydrochloride, 0.75 gram (11 grains) 
of sodium acetate and 10 c.c. (2f fluidrachms) of distilled water. 
Place the whole, contained for convenience in a porcelain capsule, 
on the water bath, and warm for at least an hour. Remove, let 
cool, and if sugar be present, even in minute quantity, a yellow 
precipitate settles out, which under the microscope is seen to con- 
sist of minute needles, generallv arranged in rosettes, which melt 
at 204° C. (399° F.). (See notes* below). 

Precautions: 

1. The mixture must not be warmed for less than an hour, or a 
glycuronic-acid crvstalline compound is formed, melting at 150° 
C. (302° F.). (See notes below). 

2. Phenylhydrazin is poisonous and, moreover, the hydro- 
chloride causes a troublesome eczema, so that caution must be 
observed not to get it on the hands. 

3. To determine the melting point of the crystals pour off the 
supernatant liquid, add water, let settle, pour off again and repeat 



SUGAR IN THE URINE. 219 

this process several times. Transfer the crystals to a watch-glass, 
dry them over sulphuric acid in a desiccator, place a small 
amount in a thin, narrow tube, fasten the latter to a thermometer 
in such a way that the substance in the bottom of the tube is 
near the bulb of the thermometer, then immerse both in a vessel 
containing oil and gradually heat until the crystals begin to fuse, 
noting the temperature indicated by the thermometer. 

Remarks: — This test is applicable in the presence of albumin 
and gives no reaction with urates, uric acid, kreatin, or kreatinin; 
nor with oxybutyric acid, urochloralic acid, uroxanthic acid, tan- 
nin, morphine, salicylic acid, or carbolic acid. Glycuronic acid 
and pentose are the only things likely to cause confusion. The 
microscopic appearance of the osazon from maltose is different 
from that of the glucose and the melting point of the latter is 
higher. 

THE INDIGO-CARMINE TEST. 

This test, known as Mulder's may be employed for the detection 
of small quantities of sugar but apparently possesses no advant- 
ages over the preceding. 

Preparation:— Make a solution of 0.2 per cent of sodium-indigo 
sulphate in acidulated distilled water, and a 25 per cent solution 
of crystallized sodium carbonate in distilled water. Add 5 drops 
of the indigo solution to 3.75 c.c. (one fluidrachm) of the sodium 
carbonate solution and heat to boiling. A green color results. 

Method of application:— -Add 10 drops of the urine to the above 
prepared green solution, heat again to boiling, and keep the fluid 
as near boiling as possible without ebullition, by holding the tube 
in the flame, withdrawing and replacing at short intervals. If sugar 
is present, the color will pass from green to violet, purple, red and 
finally straw-color without further change, the latter indicating 
presence of sugar. Urine containing 0.01 per cent of sugar will 
change the test to a red, while 0.02 per cent changes it slowly to 
the straw-color. On shaking the tube to admit oxygen of the air 
and cooling, the colors will return in the inverse order to that by 
which they appeared. The greater the proportion of sugar the 
more rapid the change to yellow. 

DELICACY OF THE TESTS. 

Trommer's test 0.0025 per cent. 

Fehling's test _ 0.0008 " " 

Nylander's test.. 0.025 " " 

Fermentation test 0.1-0.05 percent. 

Phenvlhvdrazin test.. _ 0.05 0.001 " •■ 

Polarimetric test _ 0.025-0.05 •« " 

It must be remembered, however, that testimony as to the 
delicacy of these tests in urine is conflicting, some saying, for 
example, that Nylander's test does not reveal less than 0.3 per cent 
of sugar. Williamson says that the phenylhydrazin test gives a 
reaction in dilute urine with 0.015 per cent of sugar, and that it 
is too delicate for prolonged boiling in the water bath. 



220 URINARY ANALYSIS. 



CHAPTER XXXYL 

QUANTITATIVE DETERMINATION OF SUGAR. 

The easiest method of determining the quantity 
of sugar is that by fermentation with yeast, but it 
requires 24 hours' time for its performance. Results 
are approximate, but, if certain precautions be taken, 
sufficiently accurate for clinical purposes. 

Quantitative fermentation method* : — Collect the 
whole urine for 24 hours, warm some of it to 77° F. 
(25° C.) and take the specific gravity with an urino- 
meter, standardized at 77° F. Make a note of the 
specific gravity obtained. Measure off 120 c.c. (4 
fluidounces) of the urine into a bottle, add half a cake 
of compressed yeast, crumbled into small bits, cork 
loosely, or with a nicked cork, and set aside in a warm 
place for 24 hours. Filter, warm or cool to 77° F. 
(25° C.) again, take specific gravity again. The 
specific gravity is now less than before and each 
degree lost indicates one grain of sugar per fluidounce 
of urine, or about 2.1 grams to the liter of urine. 
Hence if the specific gravity before fermentation was 
1040 and after fermentation was 1020, this urine con- 
tains 20 grains to the ounce of urine or 42 grams to 
the liter. 

Calculation of results: — The percentage of sugar 
in the urine may be calculated by multiplying degrees 
of specific gravity lost, by 0.23. Thus in the above 
example 20 times 0.23 equals 4.6 per cent, approxim- 
ately. 

Example for practice : — Urine of 24 hours measures 
900 c.c. Specific gravity before fermentation 1030, 
after fermentation 1025. Required percentage of 
sugar and total sugar voided in 24 hours. Solution: — 
1030 minus 1025 equals 5, hence the urine contains 5 
grains of sugar per ounce, or 10.5 grams per liter. 

* The writer greatly prefers this method to all those given on 
pp. 221-225. 






SUGAR IN THE URINE. 221 

Degrees lost, 5, multiplied by 0.23 equals 1.15 per 
cent of sugar present. Total urine 900 c.c, or 30 
fluiclounces, therefore total sugar equals 900 times 10.5 
divided by 1,000, or 9.45 grams in 24 hours; or 30 
times 5 equals 150 grains in 24 hours. 

Precautions necessary : — Do not set the urine 
to be fermented in a hot place or it will evaporate 
measurably in 24 hours, and an error, due to conden- 
sation of volume, will affect the specific gravity. A 
Jaksch fermentation flask is best for this purpose. 

NOTES. 

The process may be hastened, if to every 100 c.c. of 
urine 2 grammes of sodium potassium tartrate and 2 
grammes of sodium dihydrophosphate be added with 10 
grammes of compressed yeast, and the mixture allowed 
to stand at a temperature of from 30° to 34° C. Add 
0.022 to the specific gravity taken before fermentation 
to allow for addition of salts to the fermented sample. 

Quantitative determination by cnpric solutions:— Fehling's 
test-liquid may be used as follows: — Measure off 10 c.c. of Fehling's 
solution in a glass flask and dilute with 40 c.c. water. Dilute the 
urine with ten parts of water, unless the quantity of sugar is very 
small when five are to be used. Into the boiling Fehling's solu- 
tion add the diluted urine from a burette, \ c.c. at a time, until 
the solution is almost colorless, then add, drop by drop, until 
decolorization is complete. The degree of dilution of the urine 
multiplied by 5, and the result divided by the number of c.c. of 
diluted urine employed, will then indicate the per cent of sugar. 

Cause's modification of this process is to dilute 10 c.c. of Feh- 
ling's solution with 20 c.c. of distilled water, and treat with 4 c.c 
of a 1 to 20 solution of potassium ferrocyauide. While boiling, 
the diluted urine is now added, drop by drop, until the blue color 
has entirely disappeared, a precipitate not appearing at all with 
this method. 

The objections to this method are first, the great care necessary 
in preparing Fehling's solution, and second the difficulty of deter- 
mining the end reaction. It should be used only by experts. 

Purdy uses a solution and method as follows: — Cupric sulphate 
(C. P.) 4.742 grams, potassium hydroxide, (C. P.) 23.50 grams, 
strong ammonia water (Sp. Gr. 0.9) 450 c.c, glycerin (O. P.) 38 
c.c, distilled water to make 1,000 c.c The cupric sulphate and 
glycerin are dissolved in 200 cc. of water with aid of gentle heat. 
The potassium hydroxide is dissolved in another 200 c.c, and the 
two solutions are mixed. When cold the ammonia water is 
added, and the whole diluted to one liter; 35 c.c of the solution 
are measured into a flask of 200 c.c. capacity, diluted with about 
2 volumes of distilled water, and the whole thoroughly boiled. A 
graduated burette of 20 c.c capacity is filled to the zero-mark 



222 URINARY ANALYSIS. 

with the urine to be tested, and the urine slowly discharged into 
the boiling solution, drop by drop, until the blue color begins to 
fade; then still more slowly, three to five seconds elapsing after 
each drop, until the blue color completely disappears, and leaves 
the test solution perfectly transparent and colorless. If 2 c.c. 
of urine reduce 35 c.c. of the solution, 1 per cent of su^ar is pres- 
ent; if 1 c.c. of urine. 2 per cent; f c.c, 3 per cent; i c.c. 4 per 
cent; ± c.c. 8 per cent 

Carwardine's Saccharimeter:— By means of this apparatus 




Carwardine*s Saccharimeter. 



(Fig. 44) the percentage of sugar can be determined, it is said, at 
the bedside without calculations as follows: 

A. 1 — Fill measure to "F" with Fehling's solution. 
2. — Dilute by adding water to ' D F. 

3.— Pour this into test-tube. 

B. 1.— Fill burette to " U " with urine. 
2.- Dilute by adding water to • D UV 
3.— Mix. 

To estimate:— Boil A, and whilst boiling gently, add B as in 
figure. When blue color has gone quite from A, hold B upright, 
and read off percentage of sugar. 

Picric acid determination:— Dr. Johnson of England uses a 
method by which the sugar in the urine reduces picric acid and 
the color produced when compared with that of a standard solu- 
tion of ferric acetate indicates the percentage of sugar present. 
The apparatus, reagents, and directions for use can be obtained of 
Muller & Co., 405 W. 59th St., New York, who are also agents 
for Carwardine's Saccharimeter. 

Polarimetric method:— The saccharimeter of Soleil-Ventzke 
(Fig. 45) is convenient for determining sugar in urine. It is con- 
structed in such a way that, if a solution of glucose be employed, 
every entire line of division on the scale will indicate 1 per cent 
of sugar. In every case the filtered urine should be free from 
albumin, and if markedly colored, previously treated with neu- 
tral acetate of lead in substance and filtered. If it be desired to 
demonstrate the presence of sugar only, the compensators are first 
brought to the zero position. If now, upon the interposition of 



SUGAR IN THE URINE. 



223 




I IDsfi 



Fig. 45. Soleil-Ventzke Saccharimeter. 



the tube filled with urine, a difference in the color of the two 
halves of the field of vision be noted, the presence of an optically- 
active substance in the urine may be assumed and. if at the same 
time the deviation be to the right, the presence of glucose is highly- 
probable. 

Ultzraann's polarizing saccharimeter has advantages in that 
it may be adjusted to a microscope stand. The arc or fixed scale 
is so divided that one division of it represents 1 per cent of grape- 
sugar at 20° C. Results are uncertain, according to Purdy, when 
the quantity of sugar is less than 1 per cent. 

Maltose is a source of error in the polarimetric test, so that this 
substance must be tested for by the phenylhydrazin test before- 
hand. Large quantities of B-oxvbutyric acid may neutralize or 
overcome any rotation to the right due to glucose. In such cases 
the fermented urine will turn the plane of polarization still more 
strongly to the left, indicating the presence of a dextro-rotatory 
substance, in all probability glucose. 

Williamson's Method:— A test-tube of ordinary size is filled for 
about half an inch with powdered phenylhydrazin hydrochloride; 
powdered sodium acetate is added for another half inch. The 
test-tube is next half filled with urine and boiled over a spirit 
lamp. By shaking, the salts soon dissolve, and after the liquid has 
reached the boiling point the boiling is continued for two minutes. 
The tube is then allowed to stand and is finally examined for 
sugar, which is indicated by a yellowish deposit of needle-shaped 
crystals at the bottom of the tube. A urine which gives no reac- 
tion may be declared quite free from sugar for all practical 
purposes. 

Whitney's volumetric method:— F. Waldo Whitney of New 
York uses a solution and method as follows: 

The formula of the standard solution (parts by weight) is: 

GKAMME8. 

Aromonii Snlphatis (C. P.) 1.2738 

Capri Salphstis (0. P.) 2.5587 

PotHseu Hydroxid. (C. P) ... 19 1«20 

Aqcfie Amnion. (Sp. gr. 0.&0) 312.2222 

Glycerini (C P.)-- - 6l). 

Aquas (dtsc.) Q8. 



224 



URINARY ANALYSIS. 



One cubic centimeter of the reagent is the equivalent of: 

_ _. . GRAMMES. 

Cnpro-diammonintn Snlphate (N 2 H 6 Cn)S0 4 ... o 038S2 

Cupric Hyrtroxide. CnOH 2 ..... n*4infi* 

Grape Sugar, anhydrous, C 6 Br 12 06 --SSSSS ".'.'.' "S.\ 0.00526 

The sulphates of ammonium and copper are chemically com- 
bined as a double salt. It is best prepared for this reagent by 
adding chemically pure ammonium hydrate to a solution of cupric 
sulphate; a bluish precipitate falls, which redissolves in excess of 
the alkali to form a deep blue solution. Strong alcohol floated 
on the surface of the solution separates long right rhombic prisms 
which are very soluble in water; this solution constitutes aqua 
sapphirma. (Witthaus). The crystals should be dried on bibulous 
paper in vacuo and used immediately, for if they are exposed to 
the air they part with their ammonia and are converted into a 
mixture of basic sulphates. In Fehling's, Pavy's and Purdy's 
solutions the solution of cupric sulphate is added to the solution 
of caustic potash, which forms cupric hydroxide. If added to the 
ammonia it throws down the cupric hydroxide unless added to 
excess, yielding a deep purplish-blue solution that will only keen 
a longer or shorter period, according to the purity of chemicals 
used and care employed. A permanent reagent can only be pre- 
pared by chemical combination of these salts before adding- to thn 
caustic potash solution. 6 

The official potassium hydroxide contains (other than fifteen to 
twenty-eight per cent of water), from five to ten per cent of im- 
punties-viz oxide of iron, chloride, sulphate, and carbonate of 
potassium silica, lime, and alumina-and should be purified bv 
the alcohol process Digest the caustic potash in alcohol, which 
only takes up the alkaline hydrate, decant the solution from the 
precipitate evaporate to dryness, and fuse the dry mass obtained 
an ffi re - par fr e the reagent with the chemicals as described, and add 
sufficient distilled water so that 3.696 cubic centimeters (one 
drachm) are decolorized by 0.00526 gramme (one thirtieth of a 
grain) of anhydrous grape sugar.* 

testin f .° llowing tables wiU gl ve the amounts of sugar in analytical 



If reduced by 



1 minim. 

2 minims 



It contains to the ounce, 



16. gra'ns or more. 
8. grains. 
5.83 
i. 

3.20 •• 
2.67 " 
2.29 

2. •• 

1.78 grain. 
1.60 



Percentage. 



3.33 
1.67 
1.11 

0.83 
0.67 
0.56 
0.48 
0.42 
0.37 
0.33 



f™ h /vf iC T aD8 - C % Q ^ pr( ? CQ , r ^ the rea ^ en t, accurately componnded as describe 
from the Lewie Chemical Company, No. 1300 Broadway, New York. ae8cnbed ' 



SUGAR IN THE URINE. 225 

The Method of Procedure: — Heat one drachm of the reagent in a 
test-tube to boiling; add the urine slowly, drop by drop, until the 
blue color begins to fade; then more slowly, boiling three to five 
seconds after each drop, until the reagent be perfectly colorless, 
like water, or until ten drops only are added. 

It will be noted after reduction that the reagent, on cooling, 
resumes the blue color again. This change is due to the absorp- 
tion of oxygen from the atmosphere, changing the reduced sub- 
oxide held in solution to the blue protoxide again. This should 
not be mistaken for imperfect reduction or defect in the reagent. 
The change takes place quickly by shaking the tube, and the 
reduction can be repeated, if done immediately, before the evap- 
oration of the ammonia by the addition of the saccharine urine as 
before, though not with the same degree of accuracy. 

If albumin is present or a large amount of coloring matter, 
more or less of a yellow tint will be noticed. 

In samples of urine loaded with sugar, dilution with water is 
necessary, for example, if one minim of undiluted urine reduces 
the reagent there is no telling how great a percentage of sugar 
above 3.33 is present. Therefore, dilute the urine with, say, four 
parts of water and multiply the amount found by the table by the 
amount of dilution. That is if three minims of urine diluted 
with four parts of water reduce the reagent then 5.33 (see table), 
multiplied by 5 (number of volumes of urine plus water, or 1 -f- 4) 
equals 26.65 grains per ounce. To find percentage multiply 1.11 
(table) by 5, equals 5.55 per cent. 

Dilution also serves to yield more accurate results, for example, 
if 7 minims of undiluted urine reduce the reagent the urine may 
contain anywhere from 2.29 to 2.67 grains per ounce. More pre- 
cise figures may te obtained by diluting the urine, say, with one 
part water, when, if 14 minims of this diluted urine are necessary 
then the undiluted urine contains 2.21) grains to the ounce; 13 
minims, 2.46 grains; dilution with 2 parts water would show 2.20, 
2.42, and 2.54 grains. 

To determine small amounts of sugar add lead acetate to the 
urine in proportions of one- third of a grain for each degree of 
specific gravity above 1,000 up to 1,024. if pale, or 1,030 if high- 
colored; the lead salt precipitates all albumin, phosphates, sul- 
phates, chlorides, and coloring matter, but does not affect the dex- 
trose; filter until perfectly transparent and colorless, and examine. 
This treatment should be given all dense urine loaded with uric 
acid, urates, and abnormal coloring matters, even when less than 
ten minims are required, if any doubt exists in the mind of the 
examiner about the reduction of the reagent. 

Any shade of blue or green remaining in the reagent does not 
indicate sugar. The reduction with urine, thus treated, leaves the 
reagent colorless or a light amber tint, according to the amount 
required. If no sugar be present, the blue or green tint is not 
wholly dissipated, even if the dilution be carried much higher 
than in the tables given. 



226 



URINARY ANALYSIS. 



For experimental use with prepared urine, or with distilled 
water with a known trace of glucose added, a continuation of the 
table is appended: 



If beduoed by 


It contains to the ounce, 


Percentage. 


11 minims. 


1.455 grains. 


0.308 


12 


1.333 


0278 


13 " 


1.231 


0.256 


14 " 


1.144 " 


0.238 


15 » 


1.067 " 


0.222 


16 " 


1.000 M 


0.208 


17 " 


0.941 M 


0.196 


18 " 


0.869 " 


0.185 


19 •• 


0.842 " 


0.175 


20 " 


0.8U0 " 


0.167 



Experiments with the small traces, as shown in the above table, 
are of no particular clinical importance, for small traces of sugar, 
not continuous, would not indicate pathological changes, but 
show the delicate and sensitive nature of the reagent, and require 
the utmost care and precision in performing the analysis. 

In some urines a white or grayish cloud due to cuprous urate 
may be noticed or the blue color may fade to greenish but this 
has no significance. There is no reduction as long as any blue or 
green tint remains. 

MISCELLANEOUS NOTES ON SUGAR TESTING. 

Trommcr's tost. — According to Charles Piatt, of Philadelphia, 
the best way to apply this test is as follows: To urine in a test- 
tube add one-fourth its volume of 30 per cent sodium hydroxide, 
and then 10 per cent cupric sulphate solution, drop b} T drop, until 
a slight permanent precipitate is formed. Heat to boiling and, in 
presence of glucose, a reddish yellow precipitate of cuprous oxide 
separates. If glucose be present it will be noticed that the cupric 
sulphate will form a greenish-blue precipitate on coming in con- 
tact with the urine, but that on agitation this precipitate will dis- 
solve, forming a dark-blue solution, itself a satisfactory test for 
glucose in absence of sucrose and of glycogen. As most of the 
reducing substances other than sugar, which are apt to be present 
in the urine, react only at the boiling temperature, a second test 
may be prepared as described, and, without heating, allowed to 
stand twelve to twenty-four hours. If sufficient sugar be present 
a red precipitate of cuprous oxide will be obtained. The test so 
performed is practically free from the objection of other reducing 
substances, but requires a somewhat larger amount of sugar to be 
present; in other words, it is less delicate. A decolorization of 
the solution without separation of cuprous oxide is not necessarily 
indicative of sugar, nor is a precipitate forming only on cooling 
of the test. In the former case the smallest amount of cuprous 
oxide may be detected by Hoppe-Seyler's reaction with hydro- 
chloric acid. 

As an introduction to Trommer's, or, for that matter, to any 
sugar test, filtration through charcoal may be resorted to. By 
continued filtration a highly-colored urine may be reduced to a 
colorless solution practically free from reducing substances, sugar 



TESTS FOR SUGAR IN THE URIXE. 227 

included, unless the latter be in large amount. Seegen proposed 
to filter repeatedly through charcoal, to reject the filtered urine, 
to wash the charcoal carefully with distilled water, and to apply 
the tests to the washings. Charcoal filtration is, however, by no 
means so perfect a process as is Briicke's method with lead acetate. 
In this the phosphates, carbonates, sulphates, coh ring-matter, 
etc., are removed by precipitation with neutral lead acetate, or 
boiling saturated solution of lead chloride. To the filtrate am- 
monium hydroxide is added in excess, the precipitated plumbic 
glucosate is filtered off, washed carefully, suspended in water, 
decomposed by passing hydrogen sulphide, and the hydrogen sul- 
phide removed by boiling. The clear solution is then evaporated 
to the original volume of urine, allowed to stand several hours, 
again filtered, if necessary, and, finally, the filtrate is tested by 
any reliable sugar test. 

A less tedious manner of securing at least a partial separation 
of other constituents of the urine from the sugar is by Allen's 
method. (See above). 

Purdy's test.— Dr. Charles Piatt finds that in the case of 
Purdy's solution many normal urines will show a reducing power 
equivalent to from 0.2 to 0.3 per cent of glucose, this substance, 
however, being entirely absent. Deduct, therefore, 0.2 per cent 
for each 5 c.c. of undiluted urine. 

Haines' solution.— Dr. Piatt says that small amounts of sugar 
0.30 per cent, or less, are not detected by this reagent. Allen's 
modification of Fehling's test, the phenylhydrazin test, and the 
fermentation tests are more delicate. 

Briicke's modification of the bismuth test.— Dr. Piatt recom- 
mends this as one of our most reliable methods. Make up 
Frohn's reagent by dissolving 7 grammes of potassium iodide in 
20 c.c. of water. Heat and add 1.5 grammes of freshly precipi- 
tated bismuth subnitrate and about 1 c.c. of strong hydrochloric 
acid. Add a few drops of this to 10 c.c. of water in a test-tube, 
then add hydrochloric acid, drop by drop, until the precipitate 
which has formed just disappears. To 10 c.c. of urine add the 
same amount of reagent and of acid as in the preliminary trial 
test. Filter, make the filtrate strongly alkaline with sodium 
hydroxide, and boil. A black precipitate will indicate glucose. 

The Phenylhydrazin test.— Dr. Piatt performs this test as 
described above in the second method, but uses 2 grammes of 
sodium acetate. In case the crystals are not clearly revealed, the 
yellow precipitate may be separated and dissolved in hot alcohol, 
the alcoholic solution added to water in a beaker, the alcohol 
removed by evaporation and the deposit a.uain examined. This 
test is exceedingly delicate, responding to 0.001 per cent of glucose 
in aqueous solution and to 0.05 per cent in the urine. 

The fermentation method.— Dr. Piatt says that rather better 
results may be obtained by Antweiler's and Breitenbend's method 
of fermentation in presence of Rochelle salts and determination 
of the loss in weight due to evolution of carbon dioxide. This loss 
in weight multiplied bj r 2.0-45 gives the amount of glucose in the 
sample taken (2.0454 parts of glucose producing one part of carbon 
dioxide on fermentation). 



228 URINARY ANALYSIS. 



CHAPTER XXXVII. 



CLINICAL SIGNIFICANCE OF GLYCOSURIA. 

Glucose is found in the urine under the following 
circumstances : 

1. In traces in normal urine, but not recognized by 
the tests usually employed. Patients who view glyco- 
suria calmly are in the habit of asking the writer 
whether "sugar" is not found in all urine. To such 
the answer "No," should be given, especially since 
Jolles denies that even traces are present. 

2. Transitory and due to alimentary causes: — If 
a person have glycosuria from ingestion of so small an 
amount as 100 grams (about 3 ounces) of chemically 
pure glucose the condition is to be regarded as -patho- 
logic, showing a diminished power of utilizing carbo- 
hydrates in the system. Diffuse cerebral -lesions refer- 
able to alcohol and syphilis are likely to give rise to 
this digestive glycosuria, which may follow the inges- 
tion of 100 grams of glucose. In lead colic this glyco- 
suria has been observed and as a constant symptom of 
functional neuroses (grand hysteria and traumatism) ; 
also in phosphorus poisoning. 

3. Transitory in many nervous diseases: — Lesions 
affecting the central as well as the peripheral nervous 
system, such as tumors and hemorrhages at the base 
of the brain, lesions of the floor of the fourth ventricle, 
tetanus, sciatica, cerebral and spinal meningitis, con- 
cussion of the brain, in about 10 per cent of cases of 
head injury, fracture of the cervical vertebrae ; follow- 
ing epileptic, hystero-epileptic, and apoplectic seizures, 
mental shock produced by railroad accidents, etc., 
(traumatic neuroses), mental strain and worry, fatigue, 
and anxiety. (Probably due to distinct or reflex influ- 
ence affecting the floor of the fourth ventricle). 

Transitory also in certain acute febrile diseases, par- 



SUGAR IN THE URINE. 229 

ticularly during convalescence, namely, typhoid fever, 
scarlatina, measles, cholera, diphtheria, influenza, and 
especially malaria. (Due possibly to action of pto- 
mains or leukomains on the floor of the fourth 
ventricle). 

Transitory also in cases of poisoning by a number 
of substances : — Curare, chloral hydrate, sulphuric 
acid, alcohol, carbon monoxide, morphine, etc., and 
even after simple transfusion of normal salt-solution 
into the blood. 

Phloriclzin (a glucoside from the bark of the root of 
the apple tree), will likewise cause sugar to appear 
temporarily in the urine, ceasing with the withdrawal 
of the drug. 

4. Persistent in connection with certain brain 
lesions, particularly those affecting the floor of the 
fourth ventricle. 

5. Persistent in the disease known as diabetes mel- 
litus, together with more or less polyuria, and increased 
elimination of solids, except uric acid, and associated 
in advanced cases with acetonuria, lipuria, and lijpa- 
ciduria. (See further on). 

FLUCTUATIONS IN THE QUANTITY OP SUGAR IN DIABETES MELLITUS. 

According to Simon the following is true: 

1. Cases have been known in which 360 grams (5,580 grains, or 
about one pound) of sugar in 24 hours have been passed. 

2. The severity of the pathologic process cannot be measured 
by the amount of sugar eliminated. The total amount of sugar 
may not exceed a few grams daily, and yet the disease rapidly 
tend toward fatal termination. 

3. Absence of sugar from the urine in one or even more urinary 
examinations does not exclude diabetes. In such a case give the 
patient 100 grams of glucose, and test the urine three or four 
hours afterward. 

4. A light case of diabetes in which the sugar has disappeared 
under dietetic treatment may suddenly become severe, and appar- 
ently severe cases may suddenly assume a more benign type. 

5. In a type described by Hirschfeld a specific gravity of 1012 
and greatly diminished elimination of solids is noticed. 

THE BEGINNING OF DIABETES MELLITUS. 

According to Loeb the following is true: 

1. Little is known with respect to the earliest stage of diabetes. 

2. The temporary occurrence of a small quantity of sugar in the 
urine ouyht not to be regarded lightly; severe diabetes sometimes 
follows. 



230 URINARY ANALYSIS. 

3. Some cases of diabetes are acute from the first. 

4. Some cases of slight and temporary diabetes recover com- 
pletely. 

5. In a great number of cases of diabetes before a large quantity 
of sugar is excreted, small quantities are excreted temporarily, 
often for years. 

NOTES ON THE WRITER'S CASES. 

In the writer's experience the urine of all persons should be 
tested in the afternoon, about two hours following the noonday 
meal. Traces of sugar discoverable by Haines' test may be pres- 
ent at that time but absent at other hours of the day. 

In the writers experience polyuria is not a constant symptom 
among well-cared for Americans with diabetes. Not over 50 per 
cent of 70 cases seen by the writer had noteworthy polyuria, and 
in his private practice the largest amount ever collected and accu- 
rately measured was 18 pints. The mortality among all the 
poly uric cases seen in 7 years was 42 per cent, but no typical case 
of glycosuria ivithout polyuria and other marked symptoms 
proved fatal in that time. Half the writers patients voided 20 to 
40 grams of urea per 24 hours. The mortality was directly pro- 
portioned to the quantity of urea, the safest excretion being 20 to 
30 grams. The mortality in those voiding over 60 grams of urea 
was very great. 

The author has had several cases in which the patient although 
intelligent, was not aware of having any disease, even when there 
was considerable polyuria and over 1,000 grains of sugar daily. 

The thirst is greatest in cases where the percentage of sugar 
rises above 4 per cent. In a case in which there was 6 per cent of 
sugar, thirst was intense, but when, under the writer's mineral 
water treatment, the sugar fell to 4 per cent, the patient declared 
that he drank no more water than was prescribed for him. namely 
8 glasses per 24 hours, and was no more thirsty than usual. 

REDUCING SUBSTANCES OCCASIONALLY FOUND IN URINE. 

Besides glucose there are found in the urine the fol- 
lowing carbohydrates : Lactose, levulose, maltose, 
dextrin, laiose, pentose, inosite, and animal gum; cane 
sugar, and glycogen may also occur. In addition to 
these, certain acids are found which have reducing 
properties, viz., glycuronic acid and glycosuria acid. 

Levulose:— The usual tests show presence of a reducing sub- 
stance, and polarimetric examination shows a deviation to the left 
or none at all. Occasionally present in diabetic urine. 

Lactose. See Chapter XIX. 

Maltose: — The prumylhydrazin test gives crystals differing in 
appearance from those of glucose, and they melt at a temperature 
about 16° C. lower than that of the glucososazon crystals. Found 
in the urine of a person supposedly with pancreatic disease, asso- 
ciated with acholic stools. 

Dextrin: — On application of Fehling's test the blue liquid 
becomes first green, then yellow, and sometimes dark brown. 
Has been found in diabetic urine. 



SUGAR IN THE URINE. 231 

Laiose: — Titration with Fehling's solution shows from 1.2 to 
1.8 per cent more sugar than the polarimetric method. 

Pentose: — This sugar occurs in milk, tea, coffee, and wines, in 
normal urine and in diabetic urine. Salkowski says that in order 
to test for pentose take 200 to 500 c.c. (6£ to 16 fluidounces) of 
urine, and for each 100 c.c. (3 \ fluidounces) add 2-J grams (39 
grains) of phenylhydrazin dissolved in a quantity of acetic acid, 
sufficient to render the solution acid. Heat the mixture in a Bo- 
hemian-glass vessel until it begins to boil, then place in a water 
bath for an hour and a quarter. When cooled, the crystals of 
phenylpentosazon will be obtained. The crvstals melt at 158° C. 
(316.4° F.), and are dissolved by water of 60° C. (140° F.) temper- 
ature. Fermentation by ordinary yeast destroys pentose. Tollen's 
test (heating the urine with a saturated solution of phloroglucin 
in hydrochloric acid), shows pentose to be present in m«st diabetic 
urines, and in the urine of dogs rendered diabetic by ablation of 
the pancreas or by ingestion of phloridzin. 

Inosite and animal gum have already been considered. See 
Chapter XIX. 

Cane sugar may occur in traces in the urine. If containing 
other sugars as impurities it may reduce copper tests, otherwise 
not. Glycogen has been found in some diabetic urines. 

ACIDS WITH REDUCING POWER. 

Glucuronic acid:— This substance, C 6 H 10 O 7 , occurs in the urine 
abundantly after administration of such drugs as chloral, butyl- 
chloral, morphine, chloroform, camphor, curare, nitiob<mzol, etc. 
It is occasionally found in the urine of apparently healthy people. 
Detection: — Urine containing glycuronic acid reduces Haines' 
and Fehling's solutions, giving a yellow or even red precipitate, 
and rotates the plane of polarized light to the right, but fermen- 
tation with yeast shows no glucose present. Phenylhydrazin 
forms crystals, with glycuronic acid, but they differ from those 
of phenylglucosazon, being in the form of rosettes, while the 
needles are thick and plump, the whole resembling crystals of 
ammonium urate. They melt at 150 p C. (302° F.) 

Glycosuria acid: — This substance, called also uroleucinic acid, 
urrhodinic acid, and alkapton, occurs very rarely in urine. 
Urines which contain it are normal in color, when voided, but 
turn dark on standing. Glycosuric acid is more frequently found 
in the urine of children than in adults, the condition at times 
occurring in families, and persisting for years. Its significance is 
not known, though Dr. Marshall, of Philadelphia, noticed a grad- 
ually increasing weakness in a case coming under his observation. 
Glycosuric acid reduces Fehling's solution, but merely causes a 
blackish discoloration when the bismuth test is used. Fermenta- 
tion is negative. When Ehrlich's test is applied, a dark-brown 
color develops on standing for fifteen minutes, while at the end of 
an hour the urine has turned almost black. The first person to 
isolate glycosuric acid was Marshall of Philadelphia. 



232 URINAR Y ANAL YSIS. 



CHAPTER XXXYIII. 



ACETONE AND ALLIED SUBSTANCES. 

Acetone has already been alluded to in describ- 
ing diabetes mellitus, as it frequently occurs in the 
urine of that disease. This substance, a thin, color- 
less liquid of peculiar fruit-like odor, dimethyl-ketone, 
CH 3 — CO — CH 3 , occurs in small amount in normal 
urine, blood, and secretions; the amount is notably 
increased in diseases. A purely albuminous diet 
increases it after 48 hours and, in general, acetonuria 
is always due to increased albuminous decomposition. 
Continuous administration of white of eggs causes its 
appearance. It has been found in febrile diseases of 
long duration, in certain nervous diseases, as in general 
paresis, melancholia, tabes, and after epileptic seizures ; 
also in Addison's disease, general carcinomatosis, 
eclampsia, and other conditions where there is in- 
creased albuminous decomposition. 

Detection: — Distill 500 to 1,000 c.c. of urine adding 
1 gram phosphoric acid pro liter and employ the first 
10 to 30 c.c. for the following tests: 

1. Luben's test: — Treat a few c.c. of the distillate 
with several drops of a dilute solution of ioclo-potassic 
iodide and sodium hydrate ; iodoform is formed, recog- 
nized by its odor. Lactic acid and alcohol, if present, 
also form iodoform. 

2. Baeyer's indigo test : — This test may be applied 
to the urine directly. Dissolve, by aid of heat, a few 
crystals of nitro-benzaldehyde in the urine ; on cooling 
the aldehyde separates in the form of a white cloud. 
Make the solution alkaline with dilute solution of 
sodium hydroxide and, if acetone be present, first 
yellow, then green, and lastly an indigo-blue color 
will appear within ten minutes. 



ACETONE IN UEINE. 233 

3. Reynold's test: — A few c.c. of the distillate are 
treated with a small amount of freshly precipitated 
yellow oxide of mercury. (The latter is made by pre- 
cipitating solution of mercuric chloride with an alco- 
holic solution of sodium hydrate). Shake the mixture, 
filter, and add a few drops of ammonium sulphide to 
the clear filtrate. If acetone be present, a black color 
due to formation of mercuric sulphide is seen. 

Inasmuch as few physicians have the facilities for 
distilling urine, it is easier in diabetes mellitus to test 
for the next constituent to be considered, namely, 

DIACETIO AOID. 

This substance, a colorless, strongly acid liquid, also 
known as ethyl -diacetic acid, CH3.CO.CH2.CO2H, 
when found in urine, is always of pathologic signifi- 
cance. It is found especially in diabetes, in various 
forms of digestive disturbance, and in the high and 
continued fevers of children and others. It strikes a 
Bordeaux-red with solution of ferric chloride and is 
tested for as follows: To a few c.c. of urine add a 
strong solution of ferric chloride (perchloride of iron), 
drop by drop, until the precipitation of phosphates 
ceases. This may be readily observed by letting the 
precipitate settle, after a few drops of the iron solu- 
tion have been added, which it will do in about ten 
minutes. Filter, and to the filtered urine add more 
of the iron solution. If now a Bordeaux-red color 
is seen, another portion of the urine is boiled and 
similarly treated, and if this second sample give no 
reaction, suspect presence of diacetic acid. Confirm 
by treating a third portion of the urine with sulphuric 
acid, shake the mixture with ether, and draw off the 
ether. Test the ethereal extract with the iron solu- 
tion as above, and if the Bordeaux-red color be ob- 
tained, which disappears on standing for 24 to 48 
hours, diacetic acid is present, especially if acetone 
can be detected in the distillate. 

It is necessary to boil the urine, as in the second 
case above, since this procedure prevents the reaction 



234 URINAR Y ANAL YSIS. 

with diacetic acid but not the reaction with the urine 
of those who have taken various drugs, (thallin, anti- 
pyrm, salicylic acid, and phenol), also fatty acids and 
other compounds. If then, after boiling, the Bor- 
deaux-red appear, it is due to something else besides 
diacetic acid. 

CLINICAL NOTES ON ACETONE AND DIACETIC ACID. 

_ 1. The writer deems the test for diacetic acid an 
important one, as he has found it in the urine of 
several diabetics who speedily died, and has not found 
it in cases which have been apparently cured by his 
mineral-water treatment. (See Hahnemannian, Janu- 
ary and April, 1897). 

2. Jaksch proposes to substitute the term diacetic 
coma for diabetic coma, deeming the coma due to dia- 
cetic acid in the blood. 

3. Diaceturia is least significant and not uncommon 
in febrile conditions in children. • 

4. Diaceturia is especially common in the diabetes 
of children and the writer finds it an ominous sign. 
Its appearance is often preceded by diminution in the 
quantity of sugar. 

5. Diaceturia in the height of acute fevers in adults 
is of grave significance. 

_ 6. Diaceturia is sometimes a sign of anto-in toxica 
tion, so-called diacelwmia, accompanied by vomiting, 
dyspnoea, and jactitation, soon ending, "in case of 
adults, in coma and death without other discoverable 
disease or lesion. Children may recover from it. 
When acetone without diacetic acid is present, such 
cases may recover whether adults or children. 

7. The breath gives the odor of acetone (chloroform 
and acetic acid) in diabetic coma, and also, in case of 
children suffering from various febrile affections. 

8. The urine, also, in long continued fevers may 
have the odor of acetone. 

_ 9. In the gastric crises of diabetes, now well recog- 
nized, especially in cases serious from the beginning, 
acetone may be present in the urine, and the odor of 
it may be noticed in the breath. 



ACETONE IN URINE. 235 

10. Although acetone, diacetic acid, and oxybutyric 
acid appear to be connected with the phenomena of 
diabetic coma yet it is possible that they are a result 
rather than a cause of it. The presence of toxins cir- 
culating in the blood, causing an increased tissue- 
destruction, with simultaneous formation of abnormal 
acids, may possibly be the cause of the coma. (C. E. 
Simon). 

OXYBUTYRIC ACID. 

There is no easy method of detecting this substance in urine 
though its occurrence is of great clinical interest. It is an odor- 
less syrup, B-oxybutyric, or hydroxybutyric acid, C 3 H e OH.COOH, 
optically active, lsevo-rotatory, and its presence may be inferred 
if, after fermentation, the urine rotate the plane of polarized light 
to the left 



236 URINAR Y ANAL YSIS. 



CHAPTEE XXXIX. 



ABNORMAL COLORING MATTERS IN URINE. 

The following abnormal coloring matters will now 
be considered : Blood-pigments, biliary pigments, 
pathologic urobilin, melanin, the chromogen giving 
Ehrlich's reaction, and some others of less importance. 

Blood-pigments: — The tests for these have already 
been given. (See Hemoglobinuria). Htematin is a 
rare pigment which is identified by the spectroscope. 
TJroriibrolmmatin and urofuscoliCBmatin are two rare 
pigments observed by Baumstark in the urine of a case 
of pemphigus leprosus complicated with visceral lepra. 

Haeniatoporphyrin is attracting some attention now, 
as it is found in the urine during long continued ad- 
ministration of sulfonal. Urines rich in this pigment 
present an abnormal color, varying from a sherry or 
port-wine tint to Bordeaux-red. Clinically it does not 
appear to be of any special significance. Its formula 
is C 16 H ]8 N 2 03, and it is probably closely related to the 
hsematoporphyrin resulting from action of sulphuric 
acid on haeinatin. 

BILE IN THE URINE. 

Choluria shows itself by presence of the bile pig- 
ments in urine. Of these bilirubin alone occurs in 
freshly voided urine, the others forming on standing. 
Whenever the outflow of bile into the intestines be- 
comes impeded, bilirubin is absorbed by the lym- 
phatics and eliminated in the urine, icterus at the same 
time resulting. 

Color of urine containing bile: — This varies from 
a bright yellow to a greenish- brown, sometimes almost 
black. After bile has been abundant in the urine and 
has diminished to small quantities, the urine has an 
intense yellow color, resembling somewhat dilute 
potassium chromate solutions. 



COLORING MATTERS IN URINE. 237 

Odor of urine containing bile: — The odor strongly 
suggests ox-gall, and those who are familiar with this 
substance can detect bile in the urine without chemical 
tests. 

Foam of urine containing bile: — The foam of bili- 
ary urines is increased and may show, if held in the 
right light, a peculiar color, usually greenish -yellow. 

The sediment of biliary urines: — One of the easi- 
est ways to detect bile is to examine the sediment witn 
the microscope. Epithelia are stained an intense 
golden-yellow, tube-casts also. Granular casts show 
a peculiarity in this respect, certain parts of them 
being darker and more opaque than others. Filter- 
paper is also stained by biliary urine. 

Chemical tests: — Of the legion of tests for bile only 
two will be considered. 

1. RosenbacK 1 s: — This, according to Jolles, is the 
most delicate and is a modification of Gmelin's. The 
urine is filtered through thick Swedish paper, the 
latter removed, and, on the inner surface of it, is placed 
a drop of concentrated nitric acid, which has been 
allowed to stand exposed to the air for a short time. 
In the presence of bilirubin rings presenting the colors 
of the rainbow will form around the nitric acid. 

2. Happerfs test: — This is a favorite among chem- 
ists ; 10 to 20 c.c. of urine are precipitated with milk 
of lime, or a solution of barium chloride, and the pre- 
cipitate, after filtering, brought into a beaker by per- 
forating the filter and washing its contents into the 
latter with a small amount of alcohol acidulated with 
sulphuric acid. The mixture is boiled, when, in pres- 
ence of bilirubin, the solution assumes an emerald- 
green color. Urine tested for bile should be freshly 
voided. 

CLINICAL NOTES. 

1. The bile pigments in urine may appear several 
days before icterus is perceptible. 

2. They are found in urine in numerous diseases of 
the liver, in which icterus may or may not be present. 

3. The diseases in which bile is most often seen in 



238 URINAR Y ANAL YSIS. 

the urine are, besides catarrhal jaundice, biliary calcu- 
lus, parasites, compression of the duct by tumors of 
the liver, of the gall-bladder, the duct itself, and of 
neighboring structures, namely, the pancreas, stomach, 
and omentum. In diseases in which the blood pres- 
sure in the liver is lowered. In cases in which degen- 
erative processes are affecting the glandular epithelium, 
as in acute yellow atrophy or where the destruction of 
red corpuscles is going on rapidly so that the liver 
cannot transform into bilirubin all the blood pigment 
carried to it, as in pernicious anaemia, malarial intoxi- 
cation, typhoid fever, poisoning with arseniuretted 
hydrogen, etc. 

BILIARY ACIDS. 

These occur together with bile pigment and their significance 
is essentially the same. Dr. Oliver's method of detection is sim- 
ple, and as follows: 

To 20 minims of clear filtered urine reduced to 1,008 in specific 
gravity add 60 minims of test-fluid prepared as follows: 

Pulverized peptone _gr. xxx; 

Salicylic acid gr. iv; 

Acetic acid (B. P.) m. xxx; 

Distilled water to. fl. oz. viii. 

To be filtered repeatedly until transparent. 

If bile salts are present in quantity greater than normal, a dis- 
tinct milkiness promptly appears, becoming more intense in a 
moment or so. If the bile salts are in normal or less than normal 
quantity, there is no immediate turbidity, but in a short time a 
slight tinge of milkiness is seen. 

For Cholesterin see Sediments. 

PATHOLOGIC UROBILIN. 

This substance must not be confounded with normal urobilin 
(urochrome). It may be obtained, according to Gautier, from 
urochrome by submitting the latter to the action of reducing 
agents. It represents a lower form of oxidation than normal 
urobilin, and, like it, is derived from the coloring-matter of the 
blood and bilirubin. 

Color of urine containing pathologic urobilin:— This is usu- 
ally dark yellow, resembling that due to bile, and even the foam 
may be colored. 
Tests:— 

1. Huppert's test for bile (see above) gives a brownish-red pre- 
cipitate where urobilin is abundant, disappearing upon boiling 
with acidulated alcohol, the liquid at the same time becoming 
colored a brownish or pomegranate red. If but a small amount 
of the pigment is present, the liquid is colored only a light reddish 
tinge. (Jaksch's test). 



COLORING MATTERS IN URINE. 239 

2. Gerhardt's test: — Shake 10 to 20 c.c. of the urine with chloro- 
form and treat the extract with a few drops of a dilute solution of 
iodopotassic iodide. On the further addition of a dilute solution 
of sodium hydrate the chloroform extract is colored a yellow or 
yellowish-brown, and exhibits a beautiful green fluorescence 
which is even more intense than in the case of normal urobilin. 

3. If these tests fail, recourse must be had to the spectroscope. 
In acid urines or solutions urobilin presents a distinct band of 
absorption between ' ; b" and "F," extending beyond "F" to the 
right, while in alkaline solutions a band is likewise seen between 
"b" and "F" which does not extend beyond "F," and is less 
intense. 

CLINICAL NOTES ON PATHOLOGIC UROBILIN. 

1. In 12 cases of atrophic and hypertrophic cir- 
rhosis Jaksch was able to find urobilin in the urine in 
every instance. 

2. Simon has found it in a few cases of hepatic cir- 
rhosis, chronic malaria, and pernicious anaemia, in all 
of which the skin showed a light icteric hue, but bile 
pigment was absent from the urine. 

3. Urobilinuria accurs most commonly in the course 
of extensive cutaneous hemorrhages due to scars, car- 
cinoma, the hemorrhagic diathesis, etc. Individuals 
in whom this process is going on exhibit a yellowness 
of skin, but there is no bile in the urine and no 
obstruction of the bile ducts. (Jaksch). 

4. Binet has found urobilin increased in digestive 
disturbances, infectious diseases, measles, scarlatina, 
typhoid fever, and pneumonia, but scan'// in uncom- 
plicated diphtheria. 

5. Riva believes that the greater part of urobilin 
and its chromogen is of intestinal origin, but under the 
influence of modifications in the biochemical function 
of the liver not yet understood. 

6. According to llavem urobilinuria is an earlv sisrn 
of hepatic incompetence, as in the beginning of cir- 
rhosis of the liver, in cardiac cases where hepatic 
lesions are imminent, and in numerous acute affections 
in alcoholics. He thinks it a bad sign in typhoid 
fever. He finds it in newly-delivered and in nursing 
women ; also in most forms of cachexia. Relatively 
pale urines may contain it. 

7. Mya thinks urobilinuria a sign of destruction of 
the red blood corpuscles; he finis it in pneumonia, 



240 URINARY ANALYSIS. 

febrile polyarthritis, typhoid fever, and anaemias, in 
poisoning by pyridin, antipyrin, acetanilid, and other 
similar substances ; also in grave hepatic lesions. 

MELANIN. 

In cases of melanotic disease the urine, normal in color when 
voided, gradually darkens on exposure and finally becomes black. 
Such urines generally contain melanin and its chromogen in solu- 
tion. Deposits of melanin are not by themselves at all character- 
istic of melanotic tumors, being found in malarial conditions. 
Moreover melanin itself may be absent in cases of melanotic 
tumors and present in wasting and inflammatory conditions. Its 
occurrence is merely confirmatory of other symptoms of melan- 
otic tumor. 

Tests:— 

1. A few c.c. of urine are treated with bromine-water, when, in 
presence of melanin or melanogen, a precipitate will be obtained, 
which is yellow at first, and then gradually turns black. 

2. The addition to melanotic urine of a few drops of a strong 
solution of perchloride of iron will cause the appearance of a gray 
color, which is imparted to the precipitate of phosphates occurring 
at the time if more of the reagent be added, and which dissolves 
again in an excess. 

VARIOUS COLORS IN URINE. 

Phenol urines: — Certain urines darken on standing when 
melanin is absent. The color may be due to presence of various 
oxidation products of hydrochinon, as in cases of poisoning by 
carbolic acid or following the ingestion of pyrocatechin, salol, 
hydrochinon, salicylic acid and its* compounds in large doses. 

Tests:— 

1. Ferric chloride solution develops a marked violet color which 
does not disappear on standing, when salol and salicylic acid have 
been taken. 

2. In suspected carbolic acid poisoning, if the ratio of mineral 
to conjugate sulphates, normally 10 to 1, becomes greatly dimin- 
ished, without other cause, the diagnosis of poisoning by carbolic 
acid may be inferred. 

3. Tests for melanin are negative. 

Alkapton: — This substance has already been described under 
the name glycosuric acid. Urines containing it, though normal 
in color when voided, darken on standing. 

Blue urines, etc.: — These are usually referable to internal use 
of methyl blue, which is administered in the treatment of ma- 
laria, chyluria, cystitis, and other diseases. Sometimes, however, 
indican is formed within the urinary passages and colors the 
urine blue, but the occurrence is of unknown significance. Indigo 
taken internally will also color urine blue. 

Green urines occur, but the cause of the color is not definitely 
known. See Chapter IV. 

Urines containing copaiba turn red on addition of hydrochloric 
acid, and the red color is changed to violet on application of heat. 

During administration of iodine or the iodides, nitric acid turns 
urine dark mahogany and the Stokvis-Jaffe indican test develops 
a beautiful rose-red color in the chloroform. 



COLORING MATTERS IN URINE. 241 

INFLUENCE OF DRUGS, ETC. , ON THE COLOR OF URINE. 

The drug substances, named below, when taken internally, 
influence the color of the urine as follows: 

Aloes, reddish. 

Alizarin, reddish. 

Analgen, blood-red after large doses or continued use. 

Anilin chlorhydrate, external use, may cause dark red color in 
urine. 

Antipyrin, urine darker than normal. 

Arseniuretted hydrogen, poisoning by this agent, black urine. 

Bilberries, reddish. 

Blackberries, darker than normal. 

Carbolic acid, in time the urine assumes a dark to olive-green 
color, changing to blackish. 

Carrots, reddish-yellow. 

Chelidonium, brownish yellow or red; blood-red in alkaline urine. 

Cascara, yellow or reddish-yellow. 

Chrysophanic acid, yellow or orange-color. 

Coffee, strong coffee darkens the urine. 

Creosote, darkens the urine. 

Frangula (Buckthorn), yellow or reddish-yellow. 

Fuchsin, reddish. 

Gallic acid, may darken the urine. 

Gamboge, yellow more intense than normal. 

Hydrochinon, darkens the urine. 

Indigo, blue color. 

Kairin, urine darker than normal or greenish-brown. 

Logwood, darkens the urine. 

Madder, reddish. 

Methyl-blue, imparts blue color to urine. 

Mulberries, red. 

Naphtol, dark to blackish-brown color. 

Phenocoll, brown-red to blackish brown. 

Picrotoxin, yellow. 

Potassium chlorate, poisoning by this agent, black. 

Pyrocatechin, darkens the urine. 

Pyrogallic acid, external use may give urine a brown tint. 

Quinine, urine darker than normal. 

Resin, grayish-yellow, 

Resorcin, darkens the urine. 

Rhamnus, see Cascara. 

Rheum, bright-yellow, deep-yellow or greenish; alkaline urine, 
intense red. 

Salicylic acid, in large doses, smoky hue. 

Salol, dark-brown color. 

Santonin, yellow, more intense than normal; alkaline urine, 
intense red or orange-red. 

Senna, like Rheum. 

Sulphuric acid, poisoning by this agent, black urine. 

Sulphonal, at times clear dark-red, due to hsematoporphyrin. 

Tannic acid, may darken the urine. 

Tar, darkens the urine, when applied by inunction to the body. 

Thallin, yellow to brownish with a greenish tint. 

Trional, see sulphonal. 

Turpentine, often darkens the urine. 

Uva Ursi, color darker than normal. 
31 



242 URINARY ANALYSIS. 



This reaction has been called the typhoid fever reac- 
tion, due to presence of a chromogen in urine, which, 
when treated with a solution of diazo-benzene-sul- 
phuric acid and ammonia imparts a color to urine 
varying from eosin to deep garnet-red. 

Method of application: — Simon advises the test to 
be made in the following way: A few c.c. of urine 
are poured into a small test-tube, an equal quantity of 
the sulphanilic-acid mixture (see (c) below), is added 
and the whole thoroughly shaken : 1 c.c. of ammonia 
water is then allowed to run carefully down the side 
of the tube, forming a colorless zone above the yellow 
urine containing the acid. At the junction of the two, 
a more or less deeply colored ring will be seen, the 
color of which is readily distinguished, the slightest 
carmine tinge being shown readily by contrast- with 
the colorless zone above and the yellow below. If, 
now, the mixture be poured into a porcelain basin 
containing water, a salmon-red color will be obtained 
if the chromogen in question is present, but a yellow 
or orange-red when it is absent. 

Note:— The solutions required are made as follows: (a) 50 c.c. 
of hydrochloric acid are diluted to 1,000 c.c. with distilled water, 
then saturated with sulphanilic acid; (b) 5 grams of sodium 
nitrite are dissolved in 95 c.c. of distilled water; (c) a mixture is 
then made of 40 c.c. of the sulphanilic acid mixture mad3 as in (a) 
with 1 c.c. of the sodium nitrite mixture made as in (b) and this 
mixture (c) is used in performance of the tests. 

Ehrlich's original method was to add the mixture (c) to the urine 
in equal parts with ammonia in excess. His modified method was 
to add about 50 c.c. of absolute alcohol to 10 c.c. of urine, filter, 
and add to the alcoholic urine the mixture (c) from a burette, 20 
c.c. of the mixture to 30 c.c. of the alcoholic urine, adding the 
mixture in small quantities at a time and shaking thoroughly. 
Then on addition to the whole of a few drops of ammonia the 
characteristic color appears, which disappears on shaking and 
becomes permanent only after adding excess of ammonia. 

Colors obtained: — The characteristic color is car- 
mine-red; it may vary from eosin to deep garnet-red. 
An orange color may be obtained in normal urine. 
Urines containing bile may exhibit a dark cloudy dis- 
coloration changed to reddish- violet on boiling. Urine 
containing alkapton may exhibit a dark- brown color on 



COLORING MATTERS IN URINE. 243 

standing. In rare instances of diseases associated with 
well marked chills, Ehrlich's original method (see 
above) develops an intensely yolk-yellow color, even 
imparted to the foam. 

CLINICAL NOTES ON THE DIAZO REACTION. 

1. The reaction when found between the 5th and 
13th day of a disease, the diagnosis of which is in 
doubt, disappearing later, points to typhoid fever. 

2. The reaction may occur in other acute febrile 
diseases, as scarlatina, measles, small-pox, malaria, 
pneumonia, etc. 

3. The reaction is found in phthisis pulmonalis, and 
its presence for any length of time is of bad omen. 

4. Differentiation between acute miliary tubercu- 
losis and typhoid fever may be made as follows : In 
typhoid fever the reaction is usually present as early 
as the 5th or 6th day, and disappears not later than 
the 22d day; in acute tuberculosis it does not appear 
earlier than the beginning of the 3d week and then 
persists almost to the end. 

5. Absence of the reaction from the 5th to 9th day 
in typhoid usually indicates a mild case, except in 
children. Exceptions are, however, occasionally noted 
as when in severe cases the reaction is not obtained 
before the third week, and lasts only a few days. 

6. Kotheln is distinguished from measles by absence 
of it. 

7. Tubercular phthisis is differentiated from chronic 
pulmonary disease by presence of it. 

8. The reaction is occasionally obtained in the 
healthy; invariably in typhoid fever and pneumonia; 
generally in pleurisy; frequently in measles, perito- 
nitis, suppurative inflammations, erysipelas, and 
phthisis; occasionally in rhachitis and diabetes 
mellitus. 

9. It is absent in malignant and chronic non -tuber- 
cular lesions. 

10. Its absence is very valuable testimony in show- 
ing that an affection is not typhoid fever. 



244 URINARY ANALYSIS. 

11. Morphine, even in dilute solution, yields the 
diazo reaction according to Hewlett. 

CHEMICAL EXERCISE XVI. 

1. Obtain some urine containing bile; note the 
color, odor, and color of the foam. 

2. Examine the sediment with the microscope, and 
note that epithelia and various elements are stained by 
the pigments. 

3. Try Kosenbach's test and Huppert's test on 
freshly voided biliary urine. 

4. JSTote that the filtered urine will in most cases 
show a trace of albumin. 

5. Obtain the urine of a patient with typhoid fever 
after the fifth day and demonstrate Ehrlich's reaction 
in it. 



ANIMAL BASES IN URINE. 245 



CHAPTER XL. 



ANIMAL BASES IN URINE. TOXICITY OF URINE. 

Animal substances of a basic nature occur in urine, 
in small quantities in normal urine, but in larger quan- 
tities during certain pathological conditions. They 
are called ptomains or putrefactive bases, transition 
products of decomposition, that is, temporary forms 
through which matter is being transformed from the 
organic to the inorganic state by agency of bacteria 
and leucomams, products either of fermentative 
changes other than those of bacteria, or of retrograde 
metamorphoses. These compounds are of the greatest 
interest and importance in modern medical study since 
they may be regarded as the chemical causes which 
lie at the bottom of all infectious diseases, but as yet 
it must be admitted that the whole subject is wrapped 
in the deepest obscurity 

Chemical properties of the animal bases:— 

1. They resemble alkaloids, containing nitrogen, are all alkaline 
in reaction, insoluble in water, but soluble in acids forming com- 
pounds with the latter, from which compounds they are precipi- 
tated by ammonia. 

2. They are energetic reducing agents decomposing chromic 
acid, iodic acid, and silver nitrate; they give Prussian-blue with 
potassium ferrocyanide and ferric chloride. 

3. They are all oxidizable and unstable, especially under the 
influence of an excess of mineral acid, which colors them red and 
then converts them to a resinous mass . 

4. They are precipitated by numerous reagents, as picric acid, 
iodine and potassium iodide, potassio-mercuric iodide, phospho- 
molybdic acid, metatungstic and phosphotungstic acid, tannin, 
auric chloride, and iodide of potassium and bismuth in dilute 
solutions acidulated with sulphuric acid. 

Detection: — Methods for detection are tedious. The Gautier, 
Stas-Otto, or Brieger methods are usually employed. That of 
Brieger is perhaps best suited for urinary work as follows: — 
Sufficient hydrochloric acid is first added to render the urine acid, 
and the mixture is then boiled for a few minutes and filtered. 
Thefilterate is concentrated at first over aflame, and subsequently 
over a water bath, to a syrupy consistence. If the urine is foul, 
it is especially advisable to evaporate in vacuo and at the lowest 



246 URINAR Y ANAL YSIS. 

possible temperature, and as a general thing this procedure is 
useful on account of the instability of the bodies sought. 

The thick fluid is next mixed with 96-per cent alcohol, filtered, 
and the filtrate treated with a warm alcoholic solution of lead 
acetate. The resulting lead precipitate is removed by filtration 
and the filtrate concentrated — preferably in vacuo— to a syrup, 
and again taken up in 96-per cent alcohol. The alcohol is next 
evaporated, and the residue, disolved in water, is freed from lead 
by the addition of sulphuretted hydrogen and filtration. The 
filtrate is acidified with hydrochloric acid and evaporated to a 
syrupy consistence. It is then diluted with alcohol, and alcoholic 
solution of mercuric chloride is added. The resulting precipitate 
is boiled in water, and certain ptomains may separate at this stage 
in consequence of different solubilities of the double salts of mer- 
cury. The better to secure this, the precipitate may be treated 
successively with water at various temperatures. Should it be 
thought that the lead precipitate may have retained some of the 
ptomains, it may be suspended in water, the lead converted into 
sulphide, and the fluid treated in the manner just described. 

The solution obtained as above is filtered, freed from mercury, 
and evaporated; the excess of hydrochloric acid is carefully neu- 
tralized with sodium carbonate (the reaction is kept feebly acid), 
then it is again extracted with alcohol to free it from inorganic 
salts. The alcohol is evaporated, the residue dissolved in water, 
the remaining traces of hydrochloric acid neutralized with alkali, 
the whole acidified with nitric acid and treated with phosphomo- 
lybdic acid. The phosphomolybdate double compound is separa- 
ted by filtration and decomposed by neutral lead acetate or, 
more readily, by heating over a water bath. The lead is next 
removed by means of sulphuretted hydrogen (hydrogen sulphide); 
the filtrate is evaporated to a syrupy consistence and taken up 
with alcohol. Several ptomains are thus separated as hydrochlor- 
ates, and may be obtained in the form of double salts of gold, 
or platinic chloride, and of picric acid, The chloride of the 
base is obtained by removing the metallic base by precipitation 
with sulphuretted hydrogen, while the picrate is taken up with 
water, acidified with hydrochloric acid, and repeatedly extracted 
with ether to remove the picric acid. The last step is to ascertain 
if any ptomains remain in the phosphomolybdic acid filtrate after 
precipitation of the phosphomolybdic acid. 

Brieger has obtained some of his ptomains by a simpler modifi- 
cation of his above complete method. Thus he has obtained 
neurodin by treating the aqueous extract of the organic matter, 
after boiling and filtration, with mercuric chloride, collecting the 
precipitate, decomposing it with sulphuretted hydrogen, evapor- 
ating the filtrate over a water bath, and extracting the base with 
alcohol. 

Character of the bases: — Most of the members of the uric acid 
leucomains have been found in urine, namely, xanthin, paraxan- 
thin, heteroxanthin, the alloxuric bodies and bases, hvpoxanthin, 
methyl-xanthin, carnin, episarkin, epiguanin, etc. These bases 
are commonly spoken of as xanthin bases or nuclein bases since 
they are derived from the nucleins. [Kossel suggested that the 
nuclein bases be divided into two groups: Xanthin bases includ- 
ing guanin, xanthin, and its methyl derivatives, and sarkin bases 
including adenin, hypoxanthin, and their methyl derivatives. 
Uric acid constitutes a third group. Kossel and Kriiger have 



ANIMAL BASES IN URINE. 247 

lately used the term alloxuric bodies to include uric acid and 
the xanthin bases, since these contain alloxan and urea-residues. 
On the other hand, alloxuric bases include xanthin, guanin, 
adenin, hypoxanthin, heteroxanthin, paraxanthin, also theo- 
bromin, theophyllin, caffein, and carnin. Episarkin would not be 
included in this group, as it probably has only an alloxan residue]. 

Other bases which have been found are reducin, parareducin, 
and a base containing an aromatic nucleus and giving a com- 
pound with platinum chloride. Thudichum thinks urochrome 
and kreatinin basic. Pouchet has found carnin and another base 
of the composition C7H12N4O2 or C7H 14 N 4 2 ; also abase which 
he called extractive matter of urine, C3H5NO2. He regards urine 
as containing small quantities of certain pyridin bases like those 
from decomposing fish. Baumstark isolated a compound having 
the composition C s H 8 N 2 0, which could just be detected in forty 
liters of urine. Selmi succeeded in obtaining from pathological 
urines various bases which he calls pathoamins. The term uro- 
toxin is likewise sometimes used to designate the urine poison. 
Bouchard, Villiers, Lepine, Gautier, and others have apparently 
found basic substances in pathological urine. 

In general, however, it may be said that it is comparatively 
easy to find alkaloids by the so-called alkaloidal tests in urine but 
much more difficult to isolate them in a chemically pure condi- 
tion, such that their exact constitution can be determined. 

The diamins, cadaverin, and putrescin have been isolated in a 
perfectly pure condition. 

SPECIAL METHODS OF DETECTION AND ESTIMATION. 

Luff's method:— The urine of infectious diseases is examined as 
follows: Render a large quantity of the urine alkaline with 
sodium carbonate, and agitate with half its volume of ether. Let 
stand, remove ether, filter, shake with solution of tartaric acid. 
The alkaloids are removed as tartrates. Render the aqueous acid 
solution alkaline with sodium carbonate, shake with half its vol- 
ume of ether, remove ether, evaporate spontaneously, diw residue 
over sulphuric acid, and test for alkaloids by dissolving in hydro- 
chloric acid and precipitating with phosphomolybdic acid, potas- 
sio-mercuric iodide, etc. 

The alloxuric bodies and bases: — Krtiger and 
"Wulff use a copper method as follows : 100 c.c. of the 
urine freed from albumin are placed in a beaker and 
boiled ; then 10 c.c. of a 1 in 2 sodium bisulphite solu- 
tion and 10 c.c. of a 13 per cent solution of copper 
sulphate are added and the whole raised to boiling. 
Finally 5 c.c. of a 10 per cent solution of barium 
chloride are added. This causes the precipitate to 
settle rapidly and permits washing. The precipitate 
is allowed to stand two hours, then filtered through a 
10-12 cm. Swedish plaited filter and washed about 
five times with warm water (60° C). The filter and 



248 URINARY ANALYSIS- 

its moist contents are placed in a Kjeldahl round diges 
tion flask (150 c.c.), and 15 c.c. of concentrated sul- 
phuric acid added, together with 10 gm. of potassium 
sulphate and 0.5 gm. copper sulphate. On boiling for 
about one hour the solution becomes clear. The solu- 
tion is then transferred to a flask, rendered alkaline 
with sodium hydrate, and distilled. Talc can be 
advantageously used to prevent bumping. The distil- 
late is titrated with -^ oxalic acid, using rosolic acid 
as an indicator. 

By subtracting now from the nitrogen thus obtained, 
the nitrogen calculated from the uric acid estimated by 
the Salkowski-Ludwig method (see Appendix), the dif- 
ference gives the nitrogen in the alloxuric bases in 100 
c.c. of the urine. According to Baginsky, 2.8-3.8 
mg. of xanthin bases are present in 100 c.c. of urine. 
This corresponds to 0.042-0.057 gm. per day. Krtiger 
and AYulff found by the method just given that on an 
average 0.1325 gm. of alloxuric bases was excreted in 
the urine per day. The proportion of uric acid nitro- 
gen to the nitrogen of the alloxuric bases was, on an 
average, 3.82 :1. 

In a case of leukaemia, Bondzynski and Gottlieb 
found this proportion to vary from 1.06:1 to 3.22:1. 
The daily excretion of alloxuric bases was 0.5-0.6 gm. 

CLINICAL SIGNIFICANCE OF THE BASES. 

1. In acute febrile diseases, as typhoid fever, pneu- 
monia, pleurisy, and acute yellow atrophy, large 
amounts of the bases are found. Bouchard points out 
that these substances are probably formed in the lower 
portion of the intestinal tract. 

2. The diamins, putrescin and cadaverin, have been 
found in cases of cholera, pernicious anaemia, and in 
connection with cystinuria. 

3. Ptomains in notable amounts have been found in 
the urine of maniacs. 

4. In cases of extensive skin-burns, a basic substance, 
presumably peptotoxin, has been found. 

5. Toxins which in animals produce (a), convulsions ; 



ANIMAL BASES IN URINE. 249 

(5), anaemia; (<?), effects similar to those of Basedow's 
disease, have been extracted from urine. 

6. A base behaving like cholin has been found in 
the urine of Addison's disease, and a base has been 
found by Hunter in pernicious anaemia. 

7. Interest in the alloxuric bodies has been stimu- 
lated of late by investigations which go to show that 
aseptic surgical fever is due to increase of these sub- 
stances, 

8 Xanthin is said to be increased ten fold in acute 
nephritis. Vaughan finds xanthin in the sediment of 
urine in cases of enlarged spleen. 

9. Xanthin and hypoxanthin are increased in leuco- 
cythaemia owing to the increase in nucleated white 
blood corpuscles. 

Hypoxanthin is thought to be the substance once 
observed as a deposit by Bence Jones in the sediment, 
and called xanthin by him (see Sediments). 

10. Paraxanthin is thought by'Rachford to be the 
cause of migraine and other troubles. Its physiological 
action is to produce an almost rigor mortis-YikQ condi- 
tion when injected into the muscles. 

11. Modern investigators are seeking to show that 
Bright' s disease is due to irritation of the kidneys by 
passage through them of toxins, in all probability 
formed in the intestinal tract. 

The work in this field of urinary toxins already done is enor- 
mous. To describe it in full would be a volume in itself. But as 
yet it has neither become sufficiently exact to be reliable nor is it 
capable of being used for clinical purposes. It is safe to say, 
however, that medicine of the future will achieve brilliant results 
from research work in these substances. The reader is referred 
to Vaughan and Novy (third edition), for much that is interesting 
in connection with the subject. 

THE TOXICITY OF URINE. 

Bouchard's book on auto-intoxication has recently 

aroused much interest in this subject although Feltz 

and Ritter, as long ago as 1881, demonstrated the 

toxicity of normal urine by injecting it into the blood 

82 



250 URINARY ANALYSIS. 

of animals. Bocchi and Schiffer, Dupard, Lupine, 
Gu6rin, next investigated the subject, followed by 
Bouchard, Lenoir, and Charrin. Bouchard finds seven 
toxic agents in urine, namely, one diuretic, one nar- 
cotic, one sialogenous, three convulsive (two organic, 
one inorganic), and one reducing bodily heat. 

Bouchard's intravenous injections on rabbits of nor- 
mal urine show the following toxic symptoms : 

A. Myosis (contraction of pupils), accelerated respi- 
rations, somnolence and coma; also lowered body 
temperature, diminished reflexes, death from convul- 
sions or coma. 

B. The toxicity varies under certain circumstances: 

1. The urine is twofold as toxic during the day as 
during the night. 

2. The night urine is strongly convulsive. 

3. The day urine is strongly narcotic. 

4. Active muscular exercise diminishes the toxicity. 

5. The toxicity increases the longer the urine stands. 

6. If urine is decolorized, by filtering through char- 
coal, its toxicity is diminished about one-third. 

7. An aqueous extract (chiefly of the mineral ele- 
ments) causes contraction of the pupil, convulsions, 
lowered temperature, but no coma, diuresis, or saliva- 
tion. 

8. An alcoholic extract causes deep coma and diu- 
resis, but no convulsions nor myosis. 

C. In diseases the following is found : 

1. In acute uraemia the urine is non-toxic. 

2. In acute infectious diseases and fevers, if the 
kidneys remain unaffected, the urine is more toxic 
than in health. 

3. In kidney diseases, the urine is much less toxic 
than in health. 

4. In tetanus the urine is powerfully toxic. 

5. In pneumonia it is strongly toxic, producing con- 
vulsions similar to tetanic urine. 

6. In typhoid fever it is then no more toxic than 
normal urine. 

7. In cholera it produces cyanosis, convulsions, 
lowered temperature, albuminuria, and diarrhoea. 



1HE TOXICITY OF URINE. 251 

8. In leucocythaemia the urine is highly toxic, caus- 
ing convulsions and death. 

In kidney diseases, if it require 80 c.c. of urine to 
kill a rabbit of one kilogram weight, it may be assumed 
that the capacity of the kidneys is crippled about one- 
half ; if a week later only 60 c.c. are required the 
condition of the kidneys is improved. 

Apropos of this subject it may be of interest to 
quote the following from Yaughan and Eovy : 

"The chemical theory of so-called uraemia has 
received support in recent researches, notwithstanding 
the fact that the old idea that urea is the active poison 
and the theory of Frerichs that ammonium carbonate 
is the active agent, has been abandoned. 

"Landois laid bare the surface of the brain in dogs 
and rabbits, and sprinkled the motor area with kreatin, 
kreatinin, and other constituents of the urine. Urea, 
ammonium carbonate, sodium chloride, and potassium 
chloride had but slight effect ; but kreatin, kreatinin, 
and acid sodium phosphate caused clonic convulsions 
on the opposite side of the body, which later became 
bilateral. The convulsions continued at intervals for 
from two to three days, when, growing gradually 
weaker, they disappeared. Landois concludes that 
chorea gravidarum is a forerunner of eclampsia. These 
experiments have been confirmed by Leubuscher and 
Zeichen. 

' ' Falck injected into both sound and nephrotomized 
animals fresh urine, urine and the ferment of Muscu- 
lus and Lea, and urine which had undergone spontane- 
ous decomposition, without producing any symptoms 
which were comparable with those observed in uraemia. 
However, he did find that if a few drops of an infusion 
of putrid flesh were added to the urine before injection, 
all the typical symptoms of uraemia were induced. 
That the infusion of putrid flesh alone had no effect 
was also demonstrated. This would lead us to believe 
that some ferment in the infusion converts some con- 
stituent of the urine into a highly poisonous boclv. In 
this connection attention may be called to the fact 
that kreatin may be converted by the action of certain 



252 URINARY ANA LYSIS. 

germs into methyl-guanidin, which produces convul- 
sions. Whether such conversion occurs in uraemia or 
not, and if it does what the cause of it is, are ques- 
tions which must be left for future investigations to 
decide. It would be well for some one to test the brain 
and blood of a person, who had died in urseniic con- 
vulsions, for methyl-guanidin." 



URINARY SEDIMENTS. 253 



CHAPTER XLI. 



URINARY SEDIMENTS. 

Urtne on standing deposits a sediment which may- 
be recognized as follows : 

Chemical tests for sediments: — Let the glass con 
taining the urine settle for several hours. When the 
sediment forms, remove it with a pipette. An ordinary 
glass tube will serve as a pipette. Close the upper 
orifice of the tube tightly with the finger, dip the 
lower end into the sediment and remove the finger; 
urine rich in sediment runs up into the tube ; again 
close the upper orifice of the tube with the forefinger and 
remove the tube from the glass. The urine and sedi- 
ment in the tube do not flow out as long as the finger 
is tightly pressed over the upper orifice. Insert the 
lower orifice into a test-tube, remove the finger, and 
the sediment will now flow out into the test-tube 
where it may be tested in various ways as provided 
further on. In this book under the heading Chemical 
Tests for Sediments it is always assumed that the sedi- 
ment to be tested has been removed to a test-tube in 
this way, unless the centrifugal machine is used. 
When several chemical tests are to be tried, it is best 
to use several samples of the sediment in different 
test-tubes. 

The centrifugal machine accelerates and simplifies 
chemical tests for sediments. Instead of waiting sev- 
eral hours for the urine to deposit its sediment, pour 
well- shaken urine into the two or more tubes of the 
centrifuge, revolve at moderate speed (say 1,700 revo- 
lutions) for five minutes and the sediment has collected 
in the bottom of the tubes. By a clever device of Dr. 
Purdy the urine can be poured off from the sediment 
in his tubes without loss of sediment. Chemical tests 



254 



URINARY ANALYSIS. 



may then be tried without necessity of transferring 
the sediment to a test-tube. 

The following figure shows a centrifuge of modern 
make. The force exerted is enormously greater than 
that of gravity. 




Flflh 46. Purdy's electric centrifuge, used by the author. 

The sediments easily recognized, either by chemical 
means or by inspection are : 
Urates, Blood, 

Uric acid, Pus, 

Phosphates, Calcium oxalate (less easily). 

We shall consider the sediments according to the 
reaction of the urine, whether acid or alkaline. 
Acid urine: — 

1. Hold the tube containing sediment in water 
heated to 60° C. (140° to 150° F.). If it clears wholly 
or partly, urates compose the sediment. 

2. If it does not clear with heat, is of a brownish 
or yellowish color, and consists of small grains looking 
like "red-pepper grains," add a few drops of liquor 
potassae to the sediment and shake; if it dissolves, 
uric acid is present. 






URINARY SEDIMENTS. 255 

3. If the sediment is small in amount and colorless 
divide into three portions, add acetic acid to one and 
hydrochloric acid to the other, shake thoroughly. If 
the second is dissolved and the first is not, calcium 
oxalate is probably present. Confirm by adding a few 
drops of liquor potassae to third portion and notice 
insolubility. 

4. If the sediment is whitish and especially if it is 
dense and creamy white, add a few drops of liquor 
potassae to it. If it becomes greenish and gluey, per- 
haps forming viscid strings when poured from the 
tube, pus is present. The urine itself, if, pus is pres- 
ent, will always respond to the albumin test, showing 
from traces to -J- on Esbach tube. 

5. If the sediment is reddish in tint and does not 
respond to tests for urates nor appear as uric acid 
crystals, test for blood as follows : Mix equal parts of 
freshly made tincture of guaiac and old spirit of tur- 
pentine,* shake well, and cause a like amount of urine 
containing the sediment to trickle down the side of the 
tube into the guaiac-turpentine mixture. A dense yel- 
lowish precipitate (guaiac) is seen in all urines but, if 
blood be present, at the juncture of the yellow precipi- 
tate and fluid above it, is seen a blue color, slowly 
appearing. 

Use freshly voided urine in making this test. The 
urine itself will always respond to the albumin test, 
showing from traces up to the 2d mark on Esbach 
tube according to amount of blood. 

Feebly acid, neutral, or alkaline urine: — 

1. Test a whitish sediment for phosphates by add- 
ing acetic acid and shaking well. If phosphates alone 
are present, the sediment is wholly dissolved. If the 
sediment is only partly dissolved, seen by comparison 
with some of the original sediment in another tube to 
which nothing has been added, phosphates are present 
together with other constituents, probably micro- 
organisms, mucus, epithelia, and perhaps pus. 

*The turpentine should be well ozonized by exposure to air and 
light. 



256 URINARY ANALYSIS. 

2. In alkaline urine a slimy, viscid sediment, which 
sticks to the glass or is clotted and gelatinous, is pus 
mixed with mucus and needs no chemical test. Acid 
urine containing a whitish sediment, if set in a warm 
place until alkaline, will then have this stringy sedi- 
ment if pas is present. 
Urine of any reaction: — 

1. Sediments not readily recognized by any of the 
above tests are probably composed of mucus, micro- 
organisms, epithelia, and fungi. The urine of nearly all 
women contains an abundant mucous sediment which 
does not respond to the tests above. Excess of mucus 
in the urine is recognized by the slowness with which 
the urine filters. 

2. Micro-organisms in urine are readily recognized 
by the hazy appearance they give to the urine. No 
matter how long the urine stands, the haze due to 
micro-organisms will not settle. It requires a high 
speed of the centrifugal machine to settle them, 2,000 
revolutions or more. Stale urine of women with leu- 
corrhoea exhibits this haze due to countless micro- 
organisms. 

3. In urine containing sugar an abundant whitish 
sediment forms as the urine grows stale, composed of 
penicillium glaucum, a fungous growth not answering 
to the tests above given, 

In general, chemical tests for urinary sediments are 
not as satisfactory as microscopical examination, and 
are often wholly negative unless more or less tedious 
processes of separation are resorted to. 

4. Urine, if containing albumin, in no matter how 
small quantity, and depositing, if only a scanty sedi- 
ment, should be carefully examined for tube -casts with 
the microscope. A sediment so slight as hardly to be 
seen with the naked eye may contain a considerable 
number of casts. In such cases the centrifugal ma- 
chine is of great service in concentrating the scanty 
sediment. 



EXAMINATION OF URINE. 257 



CHAPTER XLII. 



MICROSCOPICAL EXAMINATION OF URINE. 

Let the urine settle six hours in a conical glass in 
case the physician does not possess a centrifugal ma- 
chine, but if the latter be at hand proceed as in chem- 
ical testing, settling for five minutes at a speed of 1,700 
revolutions, or higher if bacteria are to be examined. 
Bemove a little of the sediment by means of a pipette 
and place a small drop on a glass slide. Do not use 
cover glass at first. Procure a Bausch & Lomb micro- 
scope (Continental BB stand) with half-inch and one- 
fifth inch objectives. Always use half -inch first, focus 
by raising, not lowering the tube, and study the field. 

In a general way consider whether the objects seen 
are (a), crystalline, i. e., of definite geometrical form 
and strongly refractive of light, or (5), whether they 
are shapeless and granular, or (c), whether they are 
pale and more or less regular in form. 

We shall first suppose the objects seen are either 
crystals, or amorphous granules, and take up those 
occurring in acid urine first. 

The sediments commonly found in acid urine are 
uric acid, urates, calcium oxalate; less commonly, 
cystin, hippuric acid, kreatinin, leucin and tyrosin, 
calcium sulphate. 

SEDIMENTS OF URIC ACID. 

Occurrence: — In acid, usually sharply acid, urine, 
especially when below 1020 in specific gravity. 

Color and appearance: — Crystals visible to the 
naked eye, looking like red-pepper grains, prone to 
cling to the sides and bottom of the glass, very heavy, 
falling quickly to the bottom of the glass when the 
urine stands. Best seen by holding the glass above 
33 



258 



URINAR Y ANAL YSIS. 



the head and looking upwards. Of deep yellow or 
orange -red color, in some urines pale-yellow. 

Crystalline structure: — Primary form is a rhombic 



prism. 



and the crystals occur in various combinations 



or modifications of this form. 
Solubility: — 

1. Insoluble in acids, as hydrochloric or acetic. 

2. Soluble in fixed caustic alkalies (potassium hyd- 
roxide). 

3. Converted into ammonium urate by ammonia. 
Microscopical appearances: — Uric acid crystals 

(Fig. 47) have a rich yellow or orange color, or at least 




y hlO 



Fig. 47. Various forms of uric acid crystals. (Finlayson.) 

a pale yellow color. They occur as lozenge-shaped, 
rounded, barrel- shaped, compound, twin, cross, or 
rosette forms. In over-acid urines there are also seen 
spear-shaped or comb-and-brush-shaped crystals. They 
are easily seen with a low power (150 diameters) and 
look large with a high power (500 diameters). They 
mav occur in enormous quantities, filling the entire 
field with beautiful forms of rich coloring. 

In some urines the crystals are a pale lemon-yellow 
color and must, if hexagonal, be differentiated from 
cystin. (See Cystin). 



EXAMINATION OF URINE. 



259 



Physiology:— The uric acid sediment is normally found in some 
urines after standing ten hours or more. The tendency to sedi- 
ments of this kind is increased by rich food, animal or vegetable, 
and by bodily exercise. In the urine high acidity, poverty in 
mineral salts, low pigmentation, and high percentage of uric acid 
tend to accelerate the precipitation of uric acid in form of con- 
cretions or sediment. 

Pathology: — The sediment is probably pathological, if occuring 
in urines less than six hours old. The sooner it is deposited the 
greater the danger of formation of gravel and calculi. The de- 
posit is found: — 

1. In acute febrile disorders, and convalescence from scarlatina. 

2. When function of the heart, lungs, kidneys, and diaphragm 
is impeded. 

3. In the so-called "uric acid diathesis" (defective action of the 
liver with errors in diet, and sedentary life). 

4. In mental and physical strains (over-work, sleeplessness). 

5. In early stages of contracting kidney (interstitial nephritis). 

Diagnostic hints: 

1. In chronic nephritis if nric acid sediments occur, 
one kidney only is involved (Heitzmann). In later 
stages of nephritis the sediments are not often seen. 

2. Spear-shaped crystals indicate hyper-acid urine, 
as in gout or rheumatism. 




Fig. 48 Sharp-pointed crystals of uric acid. 

3. Clusters of uric acid crystals found in fresh urine, 
especially if spear-shaped, together with epithelia 
from pelvis of the kidney and blood corpuscles, mean 



260 URINARY ANALYSIS. 

hemorrhage in pelvis of the kidney clue to deposition 
there of sharp crystals. 

4. Constant deposit of uric acid crystals in fresh 
urine is to be regarded as a a sign of functional de- 
rangement of the liver, and possibly of undue produc- 
tion of uric acid in the body. 
Clinical notes: — 

1. Patients, in whose fresh urine uric acid crystals 
are found, quite commonly complain of pain along the 
course of the ureter and in the median line above the 
symphysis pubis. Copious ingestion of fluids has sev- 
eral times in my experience relieved such pains. 

2. Patients who have inflammatory diseases of the 
urinary organs are worse when they pass uric acid 
crystals, the latter irritating sensitive mucous surfaces. 
This should not be forgotten in the treatment. 

3. Uric acid sediments in diabetic urine seem to be 
related to the "rheumatic" pains from which some 
diabetics suffer; at any rate in one or two instances 
treatment based solely on the uric acid condition has 
resulted in marked alleviation of the pains. 

SEDIMENTS OF MIXED URATES. 

Composition: — Acid urates of sodium, potassium, 
ammonium, and (rarely) calcium. 

Occurrence: — In acid urine. (Ammonium urate in 
alkaline urine). Especially in urines of high specific 
gravity, above 1025. 

Color and appearance : — Amorphous, reddish, 
granular sediment, in color faint pinkish, fawn-color, 
reddish, or brick-red, forming what is known as the 
"brick-dust" sediment which adheres so closely to the 
sides of containing vessels, especially at the surface 
line of the urine. Scanty urines of high specific grav- 
ity are frequently turbid from presence of suspended 
urates. In the urine of children the mixed urate sedi- 
ment frequently gives the urine a "milky" appear- 
ance with but faint tint of color. 

A pellicle of urates is frequently noticed on the sur- 
face of urines containing this sediment. 



EXAMINATION OF URINE. 261 

The sediment of urates is of different color from the 
urine containing it, being deeper in hue. 

Crystalline structure: — The acid urate of sodium 
is usually amorphous, sometimes crystalline (various 
forms). The acid potassium urate is amorphous, as is 
the calcium urate. The ammonium urate is crystal- 
line, and consists of dark spheres with fine sharp 
spicula. 
Chemical tests of the mixed urate sediment: — 

1. Characteristic test : Dissolved by heat* (120° F. 
or upwards), reappearing as the liquid cools. 

2. Insoluble in 20 per cent acetic acid. 

3. Soluble in caustic alkalies, as liquor potassae. 

4. Responds to the murexide test (see uric acid). 

5. Decomposed into uric acid on addition of hydro- 
chloric acid, the former separating as brow r nish grains 
(crystals). 

6. Not readily soluble in water ; the sodium urate 
soluble with difficulty (1150 parts cold, 124 parts 
boiling) ; calcium urate very sparingly soluble. 
Microscopical appearances: — 

1. The mixed urates, when amorphous, appear 
under the microscope with a low power (150 diame- 




FlG. 49. Amorphous urates. 



*The books say "gentle heat dissolves urates." If a bottle of 
urine, turbid from urates, be set in water of temperature 140° F. 
(60° C.), in about three minutes the sediment will dissolve, 
when the urine is heated to 120° F. (50° C). 



262 



URINARY ANALYSIS. 



ters) as flocculent masses filling the entire field. With 
a high power (500 diameters) they appear (Fig. 49) as 
brown granules in a moss-like arrangement. 

2. Sodium urate, when crystalline (Fig. 50a), occurs 
in a great variety of forms. In one of Dr. Heitzmann's 
slides showing urate of sodium from a dermoid cyst of 
the kidney some of the crystals are much smaller than 
those in the figure. The crystals are more or less 
colored, brown or pink, and appear as needle-like 
clusters, in double fan-shape arrangement, or leaf- 
shaped. 

3. Ammonium urate appears with a low power (150 
diameters) as dark- brown spheres which, with a high 
power (500 diameters), are seen (Fig. 50) to be studded 




Fig. 50. Sodium urate (a), and ammonium urate (b). 

with fine, sharp-pointed spicula, so-called thorn-apple 
crystals. 

Physiology:— Normal urine precipitates urates (a) in cold 
weather; (£>) when stale. Urine two or three days old may first, 
when more acid, throw down a sediment of amorphous mixed 
urates and uric acid; later, when four or five days old and am- 
moniacal, the amorphous urate sediment becomes transformed 
into ammonium urate. 

The freshly voided urine of a healthy person shows no sediment 
of urates at ordinary temperatures, except possibly after profuse 
perspiration with diminution of amount of urine. 

Pathology:— The sediment of mixed urates may occur tempor- 
arily in: — 

1. Slight disturbances of health from over-eating or drinking 
or prolonged abstinence from either, after great exertion, revelry 
or excitement, hard study, or fright. 

2 Temporarily in slight colds, digestive disturbances in child- 
ren, and during attacks of gout. 



EXAMINATION OF URINE. 263 

3. During fevers and inflammatory diseases; in febrile exacer- 
bations of chronic diseases. 

4. More constantly in visceral disorders attended by wasting; 
in chronic affections of the heart, liver, and spleen; in functional 
disorders of the stomach; in congestions of the kidneys. 

5. In the scanty high-colored urine of dropsical patients. 

Diagnosis: — 

1. The presence of uric acid and of urates in the 
urine in form of deposits is one of the most constant 
signs of functional derangements of the liver. 

2. If without errors of diet a patient under 40 hab- 
itually passes urine which soon deposits a pinkish sed- 
iment, or which though, clear when voided soon becomes 
thick and opaque, there is undoubtedly an undue ten- 
dency to produce uric acid. 

3. In such cases as the above, possibility of the 
presence or formation of gravel or calculus is to be 
borne in mind. 

4. The richer the color of the urate sediment, the 
more the evidence of functional derangement of the 
organ in question. 

5. In acute luno: diseases the larger the amount of 
the urate sediment, the more insufficient the respiration. 

6. Eose-red urates are common in articular rheu- 
matism, acute and chronic ; in acute articular rheuma- 
tism the urates are more highly colored (by uroery- 
thrin) on the advent of pericarditis. 

7. The paler the color of the urate sediment the 
worse, usually, the condition of cutaneous functions. 

8. The sediment of urates is now thought to be 
indicative of total absence or relative insufficiency of 
disodic phosphate in the urine. 

Clinical notes: — 

1 . An occasional sediment of urates is not serious 
since it occurs even in slight disturbances of health. 
Regulation of the digestion, avoidance of late hours 
and irregular living, together with copious ingestion 
of fluids will quickly cause it to disappear. 

2. In eight or ten rapidly fatal cases from cardiac 
or renal diseases I have noticed the urine to be con- 
stantly cloudy from urates. But as in all these cases 
the urine was scanty, 15 to 20 ounces (450-600 c.c.) 



264 URINARY ANALYSIS. 

daily, I can assign no special prognostic significance 
to the sediment. 

3. In looking for tube-casts in urine containing urate 
sediments, be sure first to dissolve the sediment with 
heat just short of boiling. (See Tube-Casts). This is 
done by immersing the bottle or tube in water heated 
to 140° F. (60° C). The urate sediment will dissolve 
when the urine containing it is of a temperature of 
120° F. (50° C). 

SEDIMENTS OF CALCTUM OXALATE (OXALATE OF LIME). 

Chemical constitution and derivation: — CaC,0 4 . 

Occurrence: — Usually in acid urine, sometimes in 
alkaline.* When occurring in profusion and in sev- 
eral forms, urine usually hyper-acid. 

Color and appearance: — Light, easily-moving sedi- 
ment, usually of small bulk, and colorless. 

Crystalline structure: — Octahedra, made up of 
four-sided pyramids, situated base to base, as seen in 
their long diameters; or less commonly, ovoid or cir- 
cular discs. 
Chemical tests: 

1. Soluble in hydrochloric acid, insoluble in acetic 
acid. 

2, Insoluble in alkalies, as liquor potassae. 
Microscopical appearances: — 

Common forms : — Small, colorless crystals (Fig. 51), 
seen with difficulty with a low power (150 diameters), 
best studied with a power of 400 or 500 diameters 
octahedral in form, highly refracting; have appear- 
ance of rear of a letter envelope, i. e., squares crossed 
obliquely by two sharp lines. When small, the two 
lines form a bright spot at their crossing in the centre. 

*I cannot understand the statement of certain authors that 
oxalate of lime is a sediment characteristic of alkaline urine. 
Between January 1, 1895, and Jane 1, 1896, I found sediments of 
calcium oxalate in 116 samples of the 24 hours' urine. Of these 
98 were urines acid in reaction, 1 neutral, and 17 alkaline. In 
every case but two where there was great profusion and different 
forms of crystals, the urine was hyper-acid in reaction. 






EXAMINATION OF URINE. 



265 




Fig. 51. Various forms of calcium oxalate crystals. (Peyer) 

Edge view of the octahedra shows them as four-sided 
pyramids, base to base. Concretions of these crystals 
may occur as shown in the figure. 

Calcium oxalate also occurs in small circular crystals, 
sometimes smaller than blood corpuscles. 

Rare forms: — Large octahedra, double octahedra 
("twins"), discs, and tablets with rounded corners. 
The dumb-bell, according to Heitzmann and others, is 
the disc seen in edge view. Uric acid sometimes crys- 
tallizes as dumb-bells, but they are brownish in color. 

Calcium oxalate crystals are more easily found after 
any phosphates present have been dissolved by addi- 
tion of acetic acid, or urates cleared up by heat. 

Physiology: — Oxalate of lime, CaC 2 4) formed by the com- 
bination of oxalic acid with calcium (lime) occurs in the urine as 
sediment after eating heartily of apples especially those of the 
Spitzbergen variety, bananas, and rhubarb. In the spring when 
"pie-plant pie" is a favorite dish, oxalate sediments are common. 
A case is on record where a boy ate so much "pie-plant" and 
drank so much hard water that the oxalate crystals formed in his 
body caused haernaturia! Cabbage, carrots, spinach, asparagus, 

34 



266 URINA R Y ANAL YSIS. 

sorrel, onions, tomatoes, turnips, gooseberries, cresses, parsnips and 
saccharine articles of diet may also be responsible for the sedi- 
ment, as also an excess of fat meat. Certain beverages may 
cause a sediment of oxalate of lime; these are alkaline waters, 
carbonated drinks, fermented liquors, and sparkling wines. 

In cases when the sediment is due to food or drink it is tempor- 
ary. Persistent presence of the sediment regardless of diet is 
probably pathological, when the sediment occurs before the urine 
is 24 hours old. 

Pathology:— Insufficient activity of that stage of oxidation in 
the body which changes oxalic acid into carbonic. Hence oxalate 
of calcium sediments are found in a great variety of disorders. 

1. Due to the action of certain drugs as gentian, rhubarb, 
squill, valerian, and others. 

2. In febrile disorders. 

3. Pulmonary and cardiac affections in which respiration is 
impeded. 

4. Disorders of the hepatic system. 

5. Depressed conditions of the nervous system. 

The tendency to oxaluria is now regarded as indicating even 
more defective oxidation than the condition known as lithiasis 
(uric acid sediments). 

According to Debout d' Estrees oxaluria is more common in 
America, lithiasis more common in Europe. 

Clinical hints: — 

1. Oxalate sediments in urines of high specific 
gravity, 1026 to 1040, are found in many cases of 
nervous dyspepsia, hypochondria, or melancholia. 
Symptoms suggesting locomotor-ataxia may occur 
which, however, disappear when the digestive trouble 
is remedied. 

2. Patients with urine, as above, quite frequently 
complain of pain in the region of one kidney or the 
other, urinate frequently, and cannot retain their 
urine at times. 

3. Open air life especially in dry climates or in the 
mountains is a sovereign remedy for this class of 
patients. 

4. The tendency to ''oxaluria" lasts a long time. 
I have one patient still suffering from recurrences of 
the s} 7 mptoms after 14 years. 

5. Severe attacks of prostato-urethritis may occur 
in protracted cases of oxaluria. 

6. Stone formation is fairly common in chronic 
cases of oxaluria. Stone may be present in the kidney 
and yet oxalate crystals not always abundant, some- 
times even absent from the urine. This I have 



EXAMINATION OF URINE. 267 

observed in two cases in which calculus was subse- 
quently passed, after renal colic. 

CYSTIN IN THE SEDIMENT. 

Chemical Composition and Synonyms: — Formula, C 3 H 8 NS0 2 , 
amido-sulpho-pyruvic acid, an amide of the lactic acid series; 
contains more than 23 per cent of sulphur. Cystine. German, 
Cystin. French, Cystine. An organic substance. 

Occurrence:— A sediment seldom occurring, especially in 
strongly acid urine; when occurring is commonly in faintly acid, 
pale urine which on standing gives off odor of sulphuretted hydro- 
gen as well as that of ammonia. 

Color and appearance: — Of pale-lemon, or dirty yellowish 
gray color often changing to green on standing. 
Solubility: — 

1. Insoluble in cold and hot water, ether, alcohol. 

2. Insoluble in acetic acid. 

3. Soluble in ammonia, and in solutions of sodium and potassium 
hydroxides, as liquor potassee, but insoluble in solution of am- 
monium carbonate. 

4. Soluble in hydrochloric acid. 

5. Soluble in solutions of oxalic acid. 

6. Soluble in large excess of hot water. 
Characteristic test: — None. 

Chemical recognition:*— Let urine settle, decant, filter sedi- 
ment, wash latter with water, and (1) test on platinum foil. Cys- 
tin does not fuse but burns with a bluish-green flame and without 
melting, while a sharp, acid odor like hydrocyanic acid, is evolved. 
(If in solution in the urine, it may be precipitated by acetic acid, 
and its solubility ascertained in reagents mentioned under Solu- 
bility above.) (2) Heated with nitric acid, it dissolves with 
decomposition and, on evaporation, leaves a reddish-brown mass 
which does not give a purplish color with ammonia. 
Microscopical appearances:— Cystin may occur as hexagonal 

tablets superimposed upon or 
contiguous to one another and 
which with a power of 5' 
diameters are seen to have 
radii, which are fine lines of 
secondary crystallization. • In 
many the angles become worn 
off, approximating a circular 
form. The crystals may have 
a faint greenish tinge, or pos- 
sess an opalescent lustre sug- 
gesting mother of pearl. Less 
commonly cystine occurs as 
Fro. 52. Cystin. (DaWe,) *** ^-^Jour.ided 

dark, when out of the direct line of vision, but brilliant white 
when presented vertically to the light. 

* The value of the ferrocyauide of sodium test has been disputed by Kruken- 
berg. 



o 



o 



268 URINARY ANALYSIS. 

Micro-chemical reactions: — Differentiate from uric acid by its 
solubility in oxalic and hydrochloric acids; from triple phosphate 
by its solubility in ammonia. 

Physiology:— Cystin sediments may be noticed in the urine 
for years, especially in young men, without impairment of the 
health of the individual but they can hardly be called physiological. 

Pathology:— Some families are prone to cystin sediments and 
calculi as others are to uric acid, hence it is probably associated 
with hepatic disorders. Cystin has been found in the urine of 
Bright's disease, chlorosis, and acute articular rheumatism. Little 
is known about it. 

HIPPURIC ACID IN THE SEDIMENT. 

Microscopical Appearances: — Colorless four-sided prisms 
(Fig. 53) whose sides, when seen with a power of 500 diameters, 
sometimes show indentations. It also occurs in clusters of very 
fine needles. 




Hippuric acid. 



Note: — The writer haviDg seen a slide of hippuric acid actually 
deposited in urine, prefers to give a cut as above of a drawing of 
it rather than to copy those more elegant but less typical ones 
usually given in the books. 

Micro-chemical tests:— Differentiate from uric acid by solu- 
bility in alcohol; from triple phosphate by insolubility in acetic 
acid' The crystals are soluble in ammonia, but insoluble in 
hydrochloric acid. 

Significance:— Usually due to ingestion of certain berries as 
cranberries or bilberries; also to administration of benzoic acid, 
benzoates, and other drugs. Heitzmann says it is sometimes 
found in the sediment of the urine of diabetes. 

CALCIUM SULPHATE IN THE SEDIMENT. 

Chemical constitution and synonyms:— Calcium sulphate, 
CaS0 4 . Formed by union of sulphuric acid or sulphates with 
calcium or its compounds. Sulphate of lime, gypsum. German, 
schivefelsaurer Kalk, Gyps. French, sulphate de chaux. 

Occurrence: — A rare sediment in concentrated urines of highly 
acid reaction. 

Form: — Crystalline and sometimes amorphous. 

Color and appearance of sediment:— A whitish, heavy, dense, 
sediment. 



EXAMINATION OF URINE. 



869 



Solubility:— 

1. Sparing soluble (1-400) in cold water. 

2. More soluble in large bulk of hot water. 

3. Insoluble in ammonia and in strong hydrochloric acid. 
Characteristic te^t:— None. 

Chemical recognition:— Let urine settle, decant supernatant 
urine from sediment, filter the sediment, wash latter with cold 
water, dissolve in large bulk hot water, divide into two portions, 
test one with barium chloride, the other with ammonium oxalate. 

KREATININ IN THE SEDIMENT. 

Microscopical appearances:— According to Heitzmann kreat- 
inin sometimes appears in the sediment of acid urine. The 
crystals (Fig. 54) are colorless or at most light greenish in shape 





Fig. 54. Kreatinin. 

somewhat like those of uric acid, but seen with a power of 500 
diameters, have striations both concave and radiating. 

Note: — The cut given above is from a drawing made of a slide 
belonging to Dr. Charles Heitzmann. None of the books on 
urinary analysis in ordinary use give cuts resembling these forms. 

Significance: — The crystals shown in the figure were found in 
the urine in a case of uraemia, and are regarded by Heitzmann as 
an unfavorable sign. Small crystals of it may be found after 
excessive muscular exertion. 



LEUCIN AND TYROSIN IN THE SEDIMENT. 

Chemical constitution and synonyms:— Leucin, (leucine) C, 
HiaNOa, or C 6 H 10 (NH.>)COOH, amido-caproic acid, and tyrosin, 
(tyrosine) C 9 H u N0 3 , or C 6 tf40H.CH 3 .CH(NH 2 ).COOH, also an 
amido-fatty acid, a monobasic phenol acid. Both leucin and 
tyrosin are decomposition products of the albuminoids. German, 
Leucin, Tyrosin. French, Leucine, Tyrosine. 

Occurrence:— In urine containing excess of biliary coloring mat- 
ters. Possibly also in urine not containing bile. It is the opinion 
of Jaksch that in some instances when these bodies were supposed 
to have been in the urine that they were not sufficiently identified. 

Form: — Crystalline. — Leucin, yellowish and of greasy feel. 
Tyrosin, snow-white crystalline masses, tasteless and odorless. 
Solubility of leucin:— 

1. Insoluble in ether. 

2. Insoluble in cold hydrochloric acid. 

3. Soluble in caustic alkalies, as liquor potassae, and ammonia. 



270 URINAE Y ANALYSIS. 

alcohol""* 17 SOluble in water and in alcohol, more readily in hot 
Solubility of tyrosin:— 

1. Insoluble in alcohol and ether. 

2. Insoluble in acetic acid. 

3. Soluble in hydrochloric acid. 

4. Soluble in caustic alkalies. 

5. Difficultly soluble in cold water. 

6. Readily soluble in hot water. 

«i«SfS mic,a fecosruition. of leucinr-Concentrate the urine 
on S fil/jr°w,\ the Tif ter ^ ath V let , Rettle < decant ' collp ct sediment 
SLif ' ash - Wlth C ^ ld water ' dis solve in ammonia with addi- 
tion of ammonium carbonate, set aside, allow to evaporate then 
d?25^ fr0m t 7Sfi\ **. luting with absolute alcohol which 
dissolves some of the leucm but not the tyrosin. Let the alcoholic 
solution evaporate and test as follows- 

JS\ S f^ GT f a tes P t: - p ! ac e some of the residue on platinum foil, 
add a few drops of nitric acid and heat until it is consumed. A 
colorless residue is left. Now heat again with a drop or two of 

S wifffnrm S °l utlon and ' V^^ is P resent < W "of an oily 
fluid will form, which does not adhere to the platinum. (6) Hof- 
meister s test:-Dissolve another part of the original ammoniacal 
residue in hot water and further heat with some proto-nitrate of 
mercury; a deposit of metallic mercury occurs on the tube (c) 
fnds tT^ZIlO^m^V [ e8idue /f a ^ tube open at both 
SU, • I '■ (338 n F,) ' and lf leucm 1S P^sent it sublimes 

given off g J maSSeS ' and a sme11 of am yl-amin is 

wwS?^ al reco ^ nition of tyrosin:-Go back to the residue from 
which leucm was separated by treatment with absolute alcohol 
and test as follows: (a Place a very small particle of it on a 

rpfS?; S ^ 88 ^ m01 l ten w 1 lt | ladr °P of sulphuric acid, cover over, 
let stand half an hour, dilute with water, saturate while hot with 
calcium carbonate, filter, and treat the colorless filtrate with a 
very dilute solution of acid-free perchloride of iron (made by sub- 
liming the perchloride and dissolving sublimate in water) A 
«!?n ?p - r a g?T? rf^y destroyed by excess of the iron solu- 
i*i Enf ( / a ' Stadele /)- &) Dissolve another portion of the residue 
in hot water add a few drops of Millon's reagent (made by dis- 
solving 1 part by weight of mercury in 2 of nitric acid, heltJng 
£S£k a ?£ addlD ^ 2 P art § of water) and there arises a red pre 
(Hoffmann's test)?™ 181115 ^^ C ° l0red red t0 P ur P le " red - 

Hoffmann's test may be applied directly to an urinary sediment 
supposed to contain tyrosin. J 

Microscopical appearauces:-Leucin (Fig. 55) appears as yel- 



* m 



© 




pa 



f/i 



Fig. 55. Leucin (a) and tyrosin (&). 
lowish highly refracting spheres somewhat resembling fat gran- 
ules, though not so highly refracting, and which, with a high 



EXAMINATION OF URINE. 371 

power (500 diameters), look large. Tyrosin appears as very fine 
needles in sheaf -like collections. Crystallized from an alkaline 
solution it may occur in form of rosettes composed of fine needles 
arranged radiately. 

Micro-chemical tests:— Differentiate leucin from fat granules 
by its insolubility in ether; from ammonium urate by no decom- 
position nor separation of uric acid crystals when treated with 
hydrochloric acid. 

Physiology: — The amido-fatty acids being products of decom- 
position of protfids are not found in normal urine. They are said 
to occur physiologically in the axilla and between the toes. 

Pathology:— When retrograde changes are rapid in the body, as 
in extensive suppuration and gangrene, leucin and tyrosin are 
formed in the body in large amounts, may pass into the urine, 
and largely supplement or replace urea. 

Significance: — Sediments of leucin and tyrosin are found in 
acute yellow atrophy of the liver and in acute phosphorus poison- 
ing. Whether they occur in other diseases, as infectious dis- 
eases, is doubted. Prus has found abundance of leucin in a case 
of leukaemia. 

CALCIUM SULPHATE. 

Microscopical appearances: — Long, colorless needles, (Fig. 56), 



<^< 




Fig. 56. Calcium Sulphate. (Daiber). 

or elongated tables with abrupt extremities; sometimes also in 
dumb-bell shaped amorphous masses. 

Micro-chemical tests:— The crystals and the amorphous masses 
ar.; both insoluble in ammonia and in strong hydrochloric acid. 

Physiology: — Not found normally in urine. 

Pathology: — Concentrated urine of highly acid reaction is 
thought to be necessary for the presence of this sediment. 

Clinical significance:— Unknown or none other than given 
under Pathology. 

XANTHIN (HYPOXA.NTHIN) IN THE SEDIMENT. 

Occurrence: — A very rare sediment in acid urine. 
Form :— Cry stalline. 



272 



URINARY ANALYSIS. 



Microscopical appearances:— Lemon-shaped or whetstone- 
shaped crystals somewhat like uric- 
acid. (Fig. 57). 
Micro-chemical tests:— 

1. Differentiate from uric acid by 
solubility in ammonia without for- 
mation of ammonium urate crystals, <-- 
and by solubility in hydrochloric , 
acid. * L 

2. Insoluble in acetic acid. 
Significance:— Found by Bence 

Jones in the s^ diment of urine in * ] g- 57. Xanthin, 

case of a boy who passed a calculus (Hypoxanthin?) 

composed of it. (Neabauer). 

Note:— It is now thought that the substance is really hypoxan 
thin, not xanthiu. 






€ 



SEDIMENTS IN URINE. 273 



CHAPTEK XLIII. 



SEDIMENTS FOUND USUALLY OR ALWAYS IN ALKA- 
LINE URINE. 

These are ammonium-magnesium phosphate, sim- 
ple phosphates, and ammonium urate ; less commonly 
calcium carbonate, magnesium phosphate, soaps, 
indigo. 

SEDIMENTS OF AMMONIUM-MAGNESIUM PHOSPHATE OB 
TRIPLE PHOSPHATE. 

Occurrence: — Always in urine either alkaline or 
verging on alkalinity. 

Chemical composition : — (NH 4 ) Mg P0 4 . 6H 2 0. 
Called "triple" because of 6H 2 forming the third 
part of the formula. Result of decomposition of urea 
into ammonium carbonate and union of latter with 
magnesium phosphate. 

Color and appearance: — Phosphatic sediments are 
whitish or dirty- white. If triple phosphate crystals 
are present in large numbers, they sparkle like minute 
diamonds when the sediment is held up to a strong 
light. The urine containing it is turbid when freshly 
voided. 

Crystalline form: — Triangular prism. 
Chemical tests: — 

1. Readily soluble in acids even in 20 per cent 
acetic acid. 

2. Insoluble in solutions of the caustic alkalies, as 
liquor potassse. 

3. Red-litmus paper turned blue by ammoniacal 
urine reddens again when dry, allowing us to infer 
that the phosphatic sediment contains triple phosphate. 

4. Urine has an odor of ammonia. 

35 



274 



URINAR Y ANAL YS1 o> . 



5. A rod moistened with hydrochloric acid held 
near the urine shows fumes of ammonium chloride. 

6. Urine effervesces vigorously when acids are added 
to it. (Carbonate of ammonium decomposed by acid, 
and carbonic acid gas given off.) The foam may rise 
so fast as to bubble over from the test-tube before the 
inexperienced urine tester knows what is happening. 

Microscopical appearances: — 

Triple phosphate (Fig. 58) occurs in the form of 




Fig. 58. Ammonio-magnesium phosphate. (Daiber). 

triangular prisms, complete and incomplete. The 
colorless crystals are easily seen with a low power 
(150 diameters) and with a high power are very large. 
The incomplete forms are seen alone in slightly alka- 
line urine, or in urine which having been acid is verg- 
ing on alkalinity. The complete forms appear in 
profusion in strongly alkaline ammoniacal urine. The 
ends of the prisms are beveled. The term "coffin-lid" 
is used in describing them. Seen in edge view they 
appear as squares. Formed artificially they appear as 
star-shaped, feathery crystals (Fig. 32). Both forms 
may be artificially prepared by adding a small lump 
of ammonium carbonate to two or three ounces of 
urine and setting aside. The crystals are beautiful 
objects when seen by polarized light. 

Physiology:— Normal urine which has become stale and am- 
moniacal deposits triple phosphate. If occurring in freshly 
voided urine, the sediment is pathological. 

Pathology:— 

1. Sediment due to ammoniacal decomposition of the urine 
within the body; urea is converted into ammonium carbonate, 
which in turn gives up its ammonium to magnesium phosphate 
which is present. 

2. Sediment found in obstructive diseases of the lower urinary 
tract: retention of urine in bladder or pelvis of the kidney. Hence 



SEDIMENTS IN URINE. 275 

in diseases of the spinal cord, paralysis of the bladder, enlarged 
prostate, etc. 

3. Sediment sometimes occurs in vegetarians who are under 
mental strain; in time phosphatic stone may form in such cases, 
as well as in others. 

Clinical notes: — 

1. Triple phosphate crystals in freshly voided urine 
are common in conditions preceding ''surgical kidney" 
viz., septic inflammations of the urinary tract. 

2. The first introduction of the catheter, especially 
in cases of elderly men, is dangerous when triple phos- 
phate crystals are found in freshly voided purulent 
urine. 

3. An immense number of triple phosphate crystals 
in urine should always suggest presence of calculus, 
especially in cases where other causes for the patient's 
condition are not evident. In several cases, operations, 
or renal colic and passage of stone, have verified diag- 
noses of calculus made by the writer. 

4. The fact that the patient is voiding phosphatic 
urine does not necessarily mean presence of phosphatic 
calculus. The stone may be of any variety and set up 
inflammation with decomposition of urine and forma- 
tion of triple phosphate. 

6. In one of the writer's cases in which immense 
numbers of triple phosphate crystals were deposited, 
without pus, in the urine of a man under great mental 
strain for years, renal colic finally took place and the 
patient voided a phosphatic calculus weighing 0.4 
gramme (about six grains). The patient was after 
this free from the phosphatic sediment except occa- 
sionally when greatly fatigued or under nervous strain. 
He has gained 50 pounds in weight and in 8 years 
there has thus far been no recurrence of renal colic. 

7. In the case in which Dr. Chas. Adams removed 
a renal calculus weighing nearly half a pound (Fig. 59), 
the writer found immense numbers of triple phosphate 
crystals, together with pus, in the fresh urine. 



276 



URINARY ANALYSIS. 




Yiq. 59. Renal calculus (actual size) removed by Dr. Chas. Adams. 



SEDIMENTS IN URINE. 277 

SIMPLE PHOSPHATES (eAETHY PHOSPHATES). 

Chemical constitution: — Basic phosphates of cal- 
cium and magnesium. Caj,(P0 4 ) 2 and Mg 3 (P0 4 )2. 
Neutral calcium phosphate, CaHP0 4 . 

Occurrence: — In alkaline urine. Neutral calcium 
phosphate in feebly acid, neutral, or alkaline urine. 

Color and appearance: — The phosphatic sediment 
is light colored, usually dirty white ; may occur as a 
flocculent turbidity in freshly voided urine, which set- 
tles rather slowly and is easily disturbed by shaking. 
Occasionally the sediment is so abundant as to have a 
creamy white color and may be mistaken by the 
patient for seminal fluid. 

Chemical tests: — 

1. Urine more or less cloudy when freshly voided, 
but the sediment is not dissolved by heat. (Differen- 
tiated from urates). 

2. Readily dissolved by acids, even by 20 per cent 
acetic acid. 

3. Eed litmus paper colored blue; does not become 
red again when dried, if triple phosphate is not present 
in large quantity. (Urine alkaline from fixed alkali). 

4. The urine does not smell ammoniacal, if triple 
phosphate is not present in great quantity. 

5. A rod moistened with hydrochloric acid does 
not fume (if triple phosphate is not abundantly present). 

Note: — Both simple phosphates and triple phosphate may occur 
in the same sediment, hence tests 3, 4 and 5 are of value only 
when triple phosphate is absent or present in relatively small 
amount, ammoniacal decomposition not having as yet taken 
place. 

6. Urine effervesces on addition of acids but not so 
vigorously as when triple phosphate has been deposited 
by ammoniacal decomposition. 

7. Urine when heated becomes turbid from further 
deposit of phosphates, but the turbidity disappears 
with effervescence when an acid is added. (Differen- 
tiated from albumin). 

Microscopical appearances: — The simple phos- 
phates are either amorphous in form or, less com- 
monly, crystalline. If amorphous, (Fig. 60, A), the 



278 URINARY ANALYSIS. 

sediment appears in the form of minute pale granules 
arranged in irregular patches and sometimes mistaken 
for granular masses of organic matter. A drop of 20 
per cent acetic acid quickly dissolves this sediment on 
the slide. 

"When crystalline the sediment usually consists of 
neutral calcium phosphate, stellar or stellate phosphate, 
(Fig. 61) a rarer sediment than any other phosphatic 
deposit, save crystalline magnesium phosphate. 



^y-^M 




c 



M 



fiL'JL- <\:*&Z 






••ss 






Fig. 60. Simple Phosphates and Carbonate of Lime. 

A. Amorphous simple phosphates. S. Star-shaped simple phos- 
phates (crystalline calcium phosphate). C. Amorphous carbonate 
of lime. 31. Combination of carbonate of lime with magnesium 
salts. Magnified 300 diameters. (After Heitzmann). 

Physiology:— 

1. A slight sediment of amorphous simple phosphates recurring 
after a full meal, when the urine is naturally less acid than at 
other times can hardly be regarded as abnormal. 

2. It is said that deposits of crystalline calcium phosphate may 
take place in the urine of healthy people during the summer. 

Pathology: — Circumstances favoring increase of alkalescence 
of the blood. The sediment of earthy phosphates is in the main 
due to alkalinity of the urine and not merely to excess of phos- 
phates in the urine. The latter occurrence is rare at least in 
Chicago and vicinity and not necessarily accompanied by any 
sediment at all unless the urine at the same time happens to be 
neutral or alkaline. Urine alkaline from fixed alkali deposits 



SEDIMENTS IN URINE. 279 

earthy phosphates with usually a few crystals of triple phosphate, 
since ammoniacal decomposition usually quickly takes place in 
such urines. 

The sediment is found in cases of accumulation of carbonic 
acid in the system, as: 

1. Debility with feeble respiration, convalescences from acute 
diseases. 

2. Flatulent dyspepsia; fatty acids, formed by fermentative 
changes, being oxidized in the blood into carbonic acid, and 
carbonates formed which increase alkalescence of the blood and 
diminish acidity of the urine. 

Diagnosis: — 

1. The persistent sediment of earthy phosphates 
most frequently means flatulence of the small intestine. 
The urine when heated becomes turbid; but when 
acetic or nitric acid is added there is effervescence and 
the urine clears up. 

2. Phosphatic sediments are thought to be a sign 
of "nerve waste" but the writer has shown that they 
are not often, in fact very rarely, accompanied by any 
increase in the total phosphorus in urine, estimated as 
phosphoric acid. 

3. Kalfe speaks of cases in which there is, in addi- 
tion to the phosphatic sediment, a real increase in the 
total phosphorus in the urine ; such cases are more 
serious, may be attended by emaciation, and associated 
with phthisis, may result in diabetes insipidus, or 
alternate with diabetes mellitus. 

4. Crystalline calcium phosphate may occasionally 
be found in the urine of persons during the summer. 
Roberts regards it as often an accompaniment of 
serious disorder as cancer of pylorus, phthisis, and 
exhaustion from obstinate chronic rheumatism. It 
is also said to be found in diseases of the brain. 

Clinical notes: — 

1 . The term phosphaturia is used to designate the 
conditions in which phosphatic sediments occur in the 
urine. 

2. The patient with phosphatic sediment of simple 
phosphates is usually low-spirited, thinks he is losing 
seminal fluid, has to urinate often, is sallow, consti- 
pated or of irregular bowels, and perhaps loses flesh. 
These symptoms are quite regularly associated with 



280 URINAR Y ANAL YSIS. 

flatulent dyspepsia in debilitated persons and do not 
result from the condition of the urine. 

3. Phosphaturia has been noticed to follow gonor- 
rhoea and it then has a particularly depressing effect 
on the patient. It is also common during the period 
of sexual activity in men. 

4. It is true that spermatozoa are quite frequently 
found in urine depositing a phosphatic sediment; 
but this is not invariable nor is spermatorrhoea a neces- 
sary concomitant of phosphaturia. 

5. The phosphatic sediment in urine may be easily 
cleared up by administration of acids as benzoic, bor- 
acic, or phosphoric in sufficient doses to make the 
urine acicl. This often has a beneficial effect on the 
patient's spirits. But radical treatment is that of 
flatulent dyspepsia in most cases. 

CRYSTALLINE CALCIUM PHOSPHATE. 

Chemical constitution:— Hydrogen calcium orthophosphate, 
CaHP0 4 , 2H 2 0; (neutral calcium phosphate. neutral phosphate of 
lime), a combination of phosphoric acid with calcium in which 
one atom of the hydrogen of the acid still remains; in urinary 
sediments called stellate or stellar phosphate. 

Synonyms:— German, neutral es phosplwrsaures Calcium phos- 
phat. French, phosphate de chaux neutre. 

Occurrence: — In pale, abundant, feebly-acid, neutral, or alka- 
line urine. When found, is usually in feebly-acid urine verging 
on alkalinity. 

Color and appearance: — Occurs either in the whitish sediment 
of amorphous phosphates, or together with oxalate of lime in a 
light colored, flocculent sediment of small bulk. 

Solubility:— 

1. Not dissolved when the sediment is heated. 

2. Soluble in acids, even in twenty per cent acetic acid, espe- 
cially when shaken with it. 

3. Decomposed by ammonia. 

Chemical recognition: — If necessary the sediment may be sep- 
arated by filtration, washed, dissolved in acetic acid, tested for 
phosphoric acid with uranium nitrate, and for calcium with am- 
monium oxalate. 

Microscopical appearances:— Stellar phosphate occurs essen- 
tially as crystalline rods, usually grouped in stellar or rosette 
form, or in form of lances or wedges, but sometimes lying entirely 
uoarranged. The crystals are colorless, but under the microscope 
look dark towards the centre of the clusters. (Fig. 61). They can 
be easily seen with a low power, 150 diameters, but are best 
studied with higher. From triple phosphate they are distinguished 
by their form. 



PHOSPHATIC SEDIMENTS IN URINE. 



281 




Fig. 61. Stellar phosphate. (Beale). 

Micro-chemical tests:— 

1. Easily distinguished from uric acid by solubility without 
effervescence, when a drop of twenty per cent acetic acid is 
placed on the margin of the cover glass. 

2. Not dissolved when the sediment is warmed on the slide. 
(Differentiation from crystalline urates). 

Physiology: — The appearance of crystalline calcium phosphate 
depends on an excess of calcium phosphate in a feebly-acid urine. 
According to Bence Jones this sediment may be produced at 
pleasure by taking lime-water. 

It is said that this sediment may occur in the urine of healthy 
persons during the summer. 

Pathology:— Any condition in which an excess of calcium 
phosphate is found in feebly acid urine. 

Clinical notes:— 

1. According to some writers the sediment of stellar phosphate 
is found in cases of serious disorder of the brain. 

2. Roberts takes a gloomy view of the sediment; he regards it 
as an accompaniment of some grave disorder, as cancer of the 
pylorus, phthisis, and exhaustion from obstinate chronic rheuma- 
tism. The crystals are then plenty. 

3. My own experience is as follows: Out of 640 urinary sedi- 
ments recently examined, stellar phosphate occurred 9 times, or 1 



282 URINARY ANALYSIS. 

in 70. The patients were 6 men and 3 women. The cases were 
(1) chronic prostato-urethritis with impotence and profound men- 
tal depression; (2) paresis of the bladder from injury; (3) hyper- 
emia of the liver; (4) urine following recovery from uraemia; 
(5) nervous prostration from over-work; (6) renal calculus, removed 
by Dr. Chas. Adams; (7) debility; no other diagnosis; (8) pregnancy; 
(9) post-gonorrhceal cystitis. 

But two of these were examined during the summer. The 
crystals were plenty in all cases. 

CALCIUM CARBONATE. 

Chemical composition:— Normal or basic calcium carbonate, 
CaC0 3 . carbonate of lime, a combination of carbonic acid with 
calcium, in which the hydrogen of the acid is completely replaced 
by calcium. 

Synonyms:— German, kohlensaurer Kalk. French, carbonate 
de chaux. 

Occurrence:— A rare sediment found in alkaline urine. 

Color and appearance:— Whitish sediment like that of phos- 
phates. 

Form: — Amorphous and crystalline. 
Solubility: — 

1. Soluble in acids, even 20 per cent acetic acid, with efferves- 
cence (evolution of carbonic acid gas). 

Microscopical appearances:— Should be studied with a high 
power, 300 to 500 diameters, when it appears as dumb-bell shaped 
masses, and coarsely granular concretions. According to some 
observers it appears also as minute spherules like the spherules of 
calcium oxalate. Heitzmann's slide of carbonate of lime shows 
them somewhat prismatic in form. Fig. — gives the different 
appearances. See also Fig. 60. 

% 

.%%.$»** IS 

f '% «o95 b 

a 

Fig. 62. Calcium carbonate. 
(a) Daiber. (6) A few crystals from one of Heitzmann's slides. 

Micro-chemical tests:— Readily distinguished from uric acid 
and calcium oxalate by solubility with evolution of bubbles, when 
a drop of 20 per cent acetic acid is placed on the margin of the 
cover glass (calcium phosphate dissolves, but without bubbles). 

Pathology: — According to Heitzmann the sediment occurs in 
cases of bone caries and tuberculosis; also in rickets. 



PHOSPHATIC SEDIMENTS IN URINE, 283 

CRYSTALLINE MAGNESIUM PHOSPHATE. 

Chemical constitution:— Tribasic, or normal magnesium phos- 
phate, Mg3(P0 4 )2-22H 2 0, phosphate of magnesia, a combination 
of phosphoric acid with magnesium, in which the hydrogen of 
the acid is completely replaced by magnesium. 

Synonyms:— German, Magnesium phosphat; phosphorsaure 
Magnesia. French, phosphate de nvgnesie. 

Occcurrence: — A very rare sediment, which occurs in concen- 
trated urine of feebly acid, neutral, or alkaline reaction. 

Color and appearance:— Whitish sediment. 

Form : — Crystalline. 
Solubility:— 

1. Readily soluble in acetic acid and re-precipitated on addition 
of sodium carbonate solution. 

2. In a solution of one part by weight ammonium carbonate in 
five of water it is in time partly dissolved. (See Micro-chemical 
Tests). 

Microscopical appearances: — Crystallizes in large, highly re- 
fracting, rather long rhombic tablets or plates. (Fig. 63). They 





a b 

Fig. 63. Crystalline magnesium phosphate. 
a (Daiber). b (Jaksch). 

can be seen with a low power, 150 diameters; best studied with 

500 diameters. 

Micro-chemical tests: — 

1. Differentiate from calcium oxalate by ready solubility in 
aceti<- acid. 

2. From triple phosphate by the action of ammonium carbonate 
solution which makes them faint and after some minutes eats 
away the edges. (Triple phosphate not changed by ammonium 
carbonate). 

SOAPS OF LIME AND MAGNESIA. 

Chemical constitution:— Calcium and magnesium salts of the 
higher fatty acids. 

Occurrence:— In feebly acid urine. 

Microscopical appearances:— Crystals (Fig. 64) closely resemb- 
ling ty rosin, but not yielding the characteristic reactions of that 
body. 

Pathology:— Seen once by Jaksch in the case of a woman with 
severe puerperal septicaemia. 



284 



URINARY ANALYSIS. 






FlG. 64. Soaps of lime and magnesia. (JaJcsch). 

INDIGO IN THE SEDIMENT. 

Chemical constitution: — Derived from the decomposition of 
indoxyl sulphate (indican), the indoxyl being oxidized into indigo 
blue, thus: 2 (C 8 H 6 NOH) + 9 = C J6 H 10 N 2 O a + 2H 2 0. 
(Indoxyl.) (Indigo-blue.) 

Occurrence: — Not rare in decomposing (alkaline) urine which 
sometimes shows a bluish-red pellicle of microscopic crystals of 
indigo-blue owing to the decomposition of the indican. Found 
also at the bottom of the glass. 

Microscopical appearances:— Blue rhombic crystals and fine 
blue needles (Fig. 65), mostly cohering in clusters; also amorphous 
in flakes. 



J 



**\ 



<>^ps* 









MP 

Fig. 65. Indigo. (Daiber). 

Chemical test: — The substance when heated sublimes in violet 
vapors. 

Pathology:— Jaksch has found it in remarkable abundance in 
the ammoniacal fermentation of the urine of jaundice, and also 
in the acid urine of a case of abscess of the liver. 






BARER SEDIMENTS IN URINE. 



285 



CHAPTER XLIY. 



SEDIMENTS OF INFREQUENT OCCURRENCE. 

Certain sediments of infrequent occurrence not con- 
fined to urine of any particular reaction are the 
following : 

Fat, Cholesterin, Hsematoidin, Melanin. 



SEDIMENTS OF FAT. (LIPURIA). 

Synonyms:— German, Fett. French, Graisse. 

Occurrence:— In urine of any reaction. 

Appearance:— If abundant the urine becomes milky, but the 
milkiness is cleared by addition of ether. 

Chemical tests: — Soluble in ether; also in hot alcohol, carbon 
disulphide, and chloroform. Less soluble in benzol, insoluble in 
water. 

Microscopical appearances:— Fat appears in the sediment 
under the microscope as bright, highly refracting granules, usu- 
ally requiring a high power, 300 to 500 diameters for recognition, 
except when very abundant or 
of extraneous origin, from lubri- 
cants, etc. The margins of the 
granules are dark and somewhat 
irregular. Micro-chemically the 
granules may be seen to be dis- 
solved by ether, by placing a 
drop of the latter on the margin 
of the cover- glass. 

It may occur in the form of 
needles (Fig. 66), or be grouped 
about margaric acid needles. 
See also Fig. 67. 

Physiology: —.Fat occurs in 
the urine physiologically in or 
during: 

1. Pregnancy. 

2. Administration of fatty 
substances, as olive oil, cod-liver 
oil, etc. 

3. After inunctions 
substances. 

Pathology: — Fat is found in the urine pathologically in or dur- 
ing the following conditions: 

1. Chyluria. 

2. Fatty degeneration at some point in the urinary apparatus as 
in fatty degeneration of the kidneys, and chronic parenchyma^ 




Fig. 66. Margaric acid needles 
with fat granules grouped about 



of fatty them. (Daiber). 



286 URINARY ANALYSIS. 

tous nephritis; also where pus from an old abscess finds its way 
into the urinary passages; in pyonephrosis. 

3. Constitutional affections associated with marked cachexia or 
dependent on systemic intoxication, as phthisis, long-continued 
suppuration, pysemia, yellow fever, poisoning by phosphorus or 
carbonic oxide, poisoning from external use of carbolic acid, 
chronic poisoning by turpentine, severe injuries to the bones, 
diabetes. 

Diagnostic Hints:— 

1. If large fat granules are abundantly seen in the sediment 
with the microscope, use of the catheter may be inferred. 

2. When small fat granules are found, not due to extraneous 
matters, fatty degeneration of the kidneys is the condition, more 
certainly if fatty casts are also found. 

3. Connective tissue studded with fat granules is probably de 
rived from the kidneys. 

4. In the urine of women, fat granules of sebaceous origin 
(smegma) may be seen with the microscope in vaginal epithelia. 
and in epidermal scales from the nymphse. These are particu- 
larly noticeable in cases of vaginitis and vulvitis, as from mastur- 
bation in female children, but are not significant of the latter 
unless connective tissue be also found. (Heitzmann). 
Clinical Notes:— 

1. Recovery from parenchymatous nephritis is possible, at least 
in children, even when the sediment for months is a mass of fatty 
casts and free fat granules. In one such case, which I saw, the 
patient, a boy of eight, had for six months such a sediment in his 
urine together with a very large percentage of albumin — con- 
stantly above all figures on the Esbach tube. 

2. Purdy speaks of seeing a large amount of fat in the urine 
occurring intermittently and alternat- ., .,, . -.^ N .*..-^\j vy-v 
ing with sugar. '0tMv(f^9^&.&fi 

3. Cushing, of Boston, saw a case j&^Sf^v'^r'fc' 
in which a large amount of fat in the - ■'■[ "■: ~ ^-^^ -i : .^f: 



urine indicated not only an abscess J >': •.-■■■ v-f'i ^^]0^f >'••'.'' 
opening into the urinary tract, but ■^i^0^^'$^>'J^s''%l 
also sufficient sloughing going on to '^"^i^fer^^"'.*^''-' 
set free the oil of the fatty tissue. l^M^l&^Xt^Mc- 

4. Ebstein speaks of fat in a case of 
hydronephrosis; Henderson in heart- 
disease; various authors in diseases of 
the pancreas; in acute yellow atrophy 
of the liver. HWWM^/~&£?>: 

5. Jaksch says it may occur in the % 
form of needles (Fig. 67), especially in Yig. 67. Fat in crystalline 
connection with chronic nephritis and form. (Jaksch). 
septicaemia. 

CHOLESTERIN IN THE SEDIMENT. 

Chemical constitution:— C 2 4H 4 40.H 2 0, a fatty substance of 
alcoholoid constitution. 

Synonyms:— German, Cholesterin; Gallenfett. French, Chol- 
esterine. 

Occurrence: — A very rare sediment. 

Form:— Crystalline. 




RARER SEDIMENTS IN URINE. 



287 



Microscopical appearances:— Large, very thin, rhombic plates 
overlapping (Fig. 68) each other. Occasionally found in urine 
voided late at night, when patient is exhausted. 




Fia. 68. Cholesterin and fat granules. (Long). 



BILIRUBIN AND HJEMATOIDIN IN THE SEDIMENT. 



Bilirubin, 



Fig. 



CisHisNaOi, is an extremely rare occurrence in the 
sediment of urine. It may appear as 
amorphous yellow granules, red-brown 
rhombic tablets, or needle-form bodies 
(Fig. 69) imbedded in other substances 
(mucus, or connective tissue), as in 
nephritis or in cancer of the liver. 

Hsematoidin occurs in forms similar 
to bilirubin. Chemically it is said to 
differ, being insoluble in potassium 
hydroxide solutions, as liquor po- 
tassse, and colored transient blue by 
nitric acid. (Bilirubin soluble in 
caustic potash, colored green by 
nitric acid). 




69. Haematoidin 
(Daiber). 



MELANIN IN THE SEDIMENT. 



Constitution: — A black pigment of organic composition con- 
taining sulphur and iron, in addition to carbon, hydrogen, and 
nitrogen. 

Synonyms:— German, Melanin. French, Melanine. 

Occurrence: — Usually in solution in the urine, rarely as a 
sediment. 
Solubility:— 

1. Soluble in boiling strong mineral acids, and in boiling acetic 
and lactic acids. 

2. Soluble in strong solutions of the caustic alkalies and 
ammonia. 

3. Insoluble in cold alcohol and ether. 

4. Insoluble in acetic acid and in dilute mineral acids. 
Recognition:— Occurs in the sediment in form of small, lumpy 

granules much resembling carbon particles. 



288 URINAR Y ANAL YSIS. 

Tests:— Best applied to the urine itself. (See Melanuria). 
Pathology:— See Melanuria. 

MICROSCOPICAL EXERCISE III. 

1. Examine crystals of uric acid, noting color, and 
observe whether the crystals are sharp-pointed or not. 
Observe action of solution of sodium or potassium hy- 
droxide on the crystals, and of acetic acid (20 per 
cent). 

2. Examine crystals of triple phosphate, noting size 
and shape; also appearance of fragments. Observe 
action of acetic acid (20 per cent) on the crystals, and 
of sodium hydroxide. 

3. Examine crystals of calcium phosphate as above. 

4. Examine crystals of calcium oxalate, noting 
small size, different forms, and action of reagents as 
above, also of nitric acid. 



SEDIMENTS IN URINE. 



CHAPTEE XLY. 



ANATOMICAL SEDIMENTS IN THE URINE. 

If the objects seen with the microscope are not 
affected by the chemical or micro -chemical tests already 
described, they are probably anatomical in character 
and will, as a rule, appear pale in color, and not 
refract light sharply, though they may be regular or 
irregular in form. We distinguish corpuscles, epi- 
thelia and scales, tube-casts and similar formations, 
fungi and micro-organisms, spermatozoa, and shreds 
of connective tissue. 

Among corpuscles we find blood corpuscles, pus 
corpuscles, and mucous corpuscles. Corpuscles of all 
kinds are small, roundish bodies, visible, but not 
clearly distinguishable, with a power of 150 diameters, 
and requiring 400-500 for identification. They are 
nearer in size to small octahedra of calcium oxalate 
than to any of the other common crystals. 

Blood corpuscles: — Blood corpuscles in the urine 
present different appearances. They may be (a) nor- 
mal, like those freshly obtained, as from the finger by 
puncture with a needle ; (b) crenated ; (c) spherical or 
shrunken, with irregular outline; (d) in form of faint 
transparent rings, devoid of coloring-matter (haBmo- 
globin) from long stay in the urine. These last are 
known as blood-shadows, or ghosts, and are smaller 
than normal. 

Figure 70 shows the different ways in which blood 
corpuscles may appear in the urine, a being normal 
with biconcave appearance; &, blood shadows or 
"ghosts"; <?, crenated as in acid urine; d, spherical 
and swollen from imbibition of water. 
37 



290 UR1NAR Y ANAL YSIS. 




Fig. 70. Different appearances of blood corpuscles in the urine. 

a. Normal blood corpuscles, c. Crenated, as in acid urine. 

b. Blood shadows. d. Swollen from imbibition of water. 



RECOGNITION OF BLOOD CORPUSCLES. 

1. When blood corpuscles are abundant, urine de- 
posits a sediment varying in color from bright red to 
dark-brown or almost black. If pus is also present, 
the blood settles on top of the pus. 

2. When blood corpuscles are abundant, albumin 
is always found in the urine. 

3. The corpuscles must be examined with a high 
power, 400-500 diameters. 

4. If at all abundant in the arine, the microscopical 
field is seen to contain an immense number of small 
roundish objects, whose mass exhibits a rusty color, 
sometimes with tinge of green -yellow. 

5. The individual corpuscles show no nuclei and 
are not granular, owing to absence of cell contents. 

SIGNIFICANCE OP BLOOD CORPUSCLES. 

Presence of blood corpuscles in abundance constitutes the con- 
dition known as hcematuria. Blood in the urine occurs under the 
following conditions : 



SEDIMENTS IN URINE. 291 

Renal hematuria:— In nephritis, acute or chronic; also in renal 
hyperaemias, in lardaceous disease, in renal abscess, in cystic dis- 
eases of the kidney, in hydatids, in stone, in rare instances in 
aneurism and embolism of the renal artery and thrombosis of the 
renal vein, in cancer of the kidney, in tuberculosis of the kidney, 
in malignant forms of acute infectious diseases as small-pox, yel- 
low fever, malaria, etc.; and in leukaemia, purpura, scurvy, 
haemophilia, and filariasis; also in poisoning by turpentine, creo- 
sote, carbolic acid, cantharides, and the new synthetic com- 
pounds; in cases of uterine and crural phlebitis; as a consequence 
of injuries, blows or wounds, or indirectly from concussion. 

Lastly, it is possible to find renal hasmaturia in healthy kidneys, 
from paralysis of the vaso-constrictor nerves of the blood-vessels 
and consequent escape of the red blood corpuscles. 

DIFFERENTIAL DIAGNOSIS IN RENAL HEMORRHAGES. 

In renal hemorrhages the urine is usually acid in reaction 
(sometimes alkaline in pyelitis), of homogeneous reddish-brown 
color, of lowered specific gravity, containing blood-casts and 
renal epithelium. (See Casts and Epithelium). The sediment is 
usually more or less brown or coffee-colored in hue. The blood 
in most cases is intimately mixed with the urine (except in angio- 
neurotic cases, where the kidneys are healthy) and blood shadows 
•>r "ghosts" are numerous. Clots are usually absent, except those 
long, slender, pencil-shaped molds, due to passage through the 
ureter. (The writer has, however, seen one case of haemorrhage 
from the membranous and prostatic urethra in which such pencil- 
shaped clots were to be found). 
Differential diagnosis in renal hematurias:— 

1. Nephritis: — Presence of albumin, out of proportion to 
amount of blood, together with tube-casts, decrease in ratio of 
day urine to night; deficiency of urea or of phosphoric acid or 
increase in urea-phosphoric acid ratio (above 12 to 1). Symptoms 
and history of nephritis. 

Note: — If the proteid deposit in the Esbach tube rises above 
the figure 4 the albumin is in all probability in excess of what the 
blood would account for except possibly in excessive, persistent, 
and prostrating haemorrhages. Doubtful cases are those where, 
without casts, the proteid deposit in the Esbach tube is between 
1 and 3. The writer has seen cases where blood alone in the 
urine, without casts or evidences of nephritis, gave rise to albu- 
min in quantity such that the proteid deposit in the Esbach tube 
was between the figures 3 and 4. Albumin in such cases leaves 
the urine, when the blood disappears. 

2. Renal hypercemia:— Not much blood, not much albumin, few 
casts, scanty urine, urates or uric acid in sediment. 

3. Renal carcinoma:— Troublesome, profuse, and repeated at- 
tacks of bleeding. Persistent, burning pain in the back, partially 
relieved by rubbing and by change of position. Renal tumor and 
cachexia. Pus not abundantly present in the urine. Albumin 
not in excess of blood. Bleeding much more profuse at times 
than at others, with weeks or months interval. 

4. Renal tuberculosis: — Urine contains, besides blood, more or 
less pus, broken-down debris settling with difficulty; intermittent 
haematuria, usually no pain, but tumor may be present. Emacia- 



292 URINARY ANALYSIS. 

tion, elevation of temperature; detec.ion aid propagation of 
bacillus tuberculosis. 

5. Renal stone: — Blood usually diminishes, when the patient is 
at rest. Albumin small in quantity, pus corpuscles always found, 
crystals usually. Fixed pain in region of the kidney, wincing on 
part of patient on deep pressure over kidney at a certain point, 
pain down course of ureter, sometimes with retraction of testicle, 
and often extending down the thigh. 

6. Malarial hcematuria: — Absence of nephritis and other signs 
with history of malaria and presence of Plasmodium malarial in 
blood. 

7. Bleeding from healthy kidneys, often symptomless: — Due to 
over-exercise, haemophilia, or angio-neurosis. In the latter cases 
there may be renal tenderness on deep pressure. In one purely 
angio-neurotic case (diagnosis verified by operation), which the 
author saw, the blood on some occasions separated completely 
from the urine, leaving clear normal urine above the sediment. 
In such cases settle the blood in the centrifuge at low speed, pour 
off supernatant urine, and settle this at high. The urine settled 
at high speed shows nothing but blood-corpuscles, as does that at 
low. [In cases of symptomless haematuria put the patient on 
milk-diet, give baths, and keep quiet for several weeks, using also 
suggestive treatment. (The writer has found 30-drop doses of 
tincture of Thlaspi Bursa Pastoris useful in the purely angio- 
neurotic cases, but it was of no value in a case of haemophilia in 
which it was tried). If the haemorrhage is overcome by the above 
treatment, it is probably angio-neurotic. The writer thinks these 
cases not so rare as might be imagined]. 

Hematuria from bladder: — The urine is usually alkaline, often 
ammoniacal and thick from muco-pus, clots are commonly found, 
blood is brighter red and not intimately mixed with urine. Blood 
clots of irregular form and large size are from bladder; epithelia 
from middle layers of the bladder are quite commonly found. 
The ratio of day urine to night is not usually permanently or seri- 
ously changed in purely vesical haemorrhages. 

DIFFERENTIAL DIAGNOSIS IN VESICAL HEMORRHAGES. 

1. Blood in the urine in small quantities, together with pus, in 
the case of old men, is quite common, as in the cystitis from en- 
larged prostate. 

2. Blood in cases of stone in the bladder is almost normal in 
appearance, and is passed mostly at the end of micturition. 

3. In inflammations of the neck of the bladder, blood, in small 
quantity, may be passed at the end of micturition. History of 
recent gonorrhoea, and presence of considerable albumin (i to 1£ 
in the Esbach tube) will serve to distinguish from stone. 

4. Profuse vesical haemorrhages occur in connection with 
growths in the bladder. Dilute the urine abundantly with water; 
the blood-corpuscles are dissolved, and flesh-colored fibers or 
shreds easily found. (See Connective Tissue for figure). Epi- 
thelia from middle layers of the bladder are usually abundantly 
present in such cases. 

Hematuria from urethra:— Recognized by flow of blood be- 
tween micturitions or when blood can be squeezed out of the 
meatus by pressure. Usually due to gonorrhoea (acute stage), 
chancre, growths, injuries, or surgical operations. 



SEDIMENTS IN URINE. 293 

MISCELLANEOUS CLINICAL NOTES. 

1. An alternation of clear and bloody urine in the same day is 
never seen in haematuria due to bladder tumors. 

2. The urine voided three hours after eating is sometimes more 
than ordinarily bloody in cases of calculous pyelitis, or in cancer 
of the kidney. 

3. Blood from the seminal vesicles will be clotted and mixed 
with yellow bodies and spermatozoa. If the spermatic fluid is 
bloody, the blood probably comes from the prostatic sinus. 

4. Symptoms of malarial haematuria sometimes resemble those 
of stone in the bladder, namely, frequent painful micturition, 
vesical tenesmus, sacral pain, and sleeplessness; but in addition 
there are in malarial haematuria, rigors, usually daily, fever, and 
sweat for several hours, and beginning usually at the same hour. 

5. Laceration of the kidney may occur from accident without 
external appearance of injury; the symptoms are haematuria, pain 
in the loins, possibly pus in the urine, typhoid condition, and 
death in a few weeks. 

6. Keyes reports that much albumin and tube-casts may be 
found in some cases of haematuria from enlarged prostate. 

7. Vicarious menstruation by the kidneys is possible and spon- 
taneous, and even regular monthly haematuria has been noticed in 
males. 

8. Renal haematuria may follow the high temperature of typhoid 
fever, disappearing on the fall of the fever. 

9. Renal haematurias may be due to over-doses of turpentine, 
and also to certain well-known and much-puffed synthetic com- 
pounds now on the market. Vesical haemorrhages may be due to 
overdoses of cantharides. 

10. Haemorrhage from the bladder is sometimes due to rupture 
of varicose veins, especially in elderly patients. 



2*1 UBINARY ANALYSIS. 



CHAPTER XLYI. 



PUS CORPUSCLES IN THE URINE. 
MUCOUS CORPUSCLES. 

Recognition of pus by chemical means has already 
been described. Microscopically we rind pus corpus- 
cles; these are about one- third larger than blood cor- 
puscles, granular, and sometimes showing nuclei. The 
latter may be brought out by addition of acetic acid. 

Figure 71 shows pus corpuscles. 







Fig. 71. a. The usual globular pus corpuscles of acid urine. 
b. Irregular pus corpuscles of acid urine, provided with pro- 
cesses, c. Swollen pus corpuscles of a strongly dilute or alka- 
line urine, with visible nuclei. (Ultzmann). 

RECOGNITION OF PUS CORPUSCLES. 

1. Urine containing abundance of pus corpuscles 
deposits a dense white or greenish-white sediment. 
In less abundance the deposit is flocculent. 

2. At least a trace of albumin is to be found in the 
urine, but seldom a large quantity. The precipitated 



PUti CORPUSCLES IN URINE. 293 

proteicls in the Esbach tube will settle below the 
figure 1. 

3. The corpuscles must be examined with a high 
power, 400-500 diameters. 

4. If at all abundant, the field is seen to contain an 
immense number of small, colorless, roundish objects, 
granular and sometimes exhibiting nuclei. 

5. In ammoniacal urine it is hard to see the indi- 
vidual corpuscles, which have broken up and coalesced 
to form a granular mass. 

6. In strongly dilute or alkaline urine they are 
much swollen, and have visible nuclei in the central 
portion, while the peripheral portions show only a 
small number of granules. 

7. In acid urine they are small and either globular, 
or else irregular, sending out processes. The latter 
occur in the more obstinate cases of pyuria. 

8. Solution of iodine in potassium iodide colors pus 
corpuscles a fine yellow, while the nuclei appear 
darker and of a brown-yellow color. 

SIGNIFICANCE OF PUS CORPUSCLES. 

In the urine of women pus corpuscles may merely indicate leu- 
corrhoea. Whenever found, the urine should be examined after 
a cleansing vaginal injection or use of vaginal tampon. Pus in 
the urine is found in a large number of pathological conditions. 
It may be due to chronic diffuse nephritis, renal abscess, tubercu- 
losis, cancer, or calculus; and is found in pyelitis, pyelo-nephritis, 
pyonephrosis, cystitis due to various causes, urethritis, prostatitis, 
etc., etc. 

DIFFERENTIAL DIAGNOSIS IN PYURIA 

1. Pus from the kidneys is usually found in acid urine together 
with casts and renal epithelium. It settles quickly on standing, 
and is flocculent. The patient is usually sensitive to pressure over 
one kidney or the other, and may show presence of a tumor. 
When pus is retained in the calices, chills are often present. If 
the pus is only in the pelvis of the kidney, casts will be absent or 
scanty, and albumin not large in amount, below 1 on the Esbach 
tube. Frequent urging to urinate will not be a persistent symp- 
tom, though it may be complained of for a time. 

2. When pus is from the bladder, the deposit is glairy and 
sticky, if the urine is ammoniacal, and there are found triple 
phosphate crystals with large, flat, and often round epithelia. 
Frequent and painful micturition is the rule in such cases. 

In acute inflammation of the neck of the bladder the urine is 
acid, and it may appear that the pus is from the kidney, but 
albumin will be fairly abundant, perhaps settling to 1, or higher, 



296 URINA R Y ANAL YSIS. 

in the Esbach tube with frequency, straining after urination, and 
doubtless a history of recent gonorrhoea. 

Pus from the prostate may show itself in the form of "threads" 
in the urine. The microscopic appearance of these threads is 
shown in Fig. 72. 




Fig. 72. A so-called gonorrhceal thread, consisting of pus cor- 
puscles and urethral epithelium. (Ultzmann). 

3. Pus from the urethra may be squeezed out between the acts 
of micturition, and the bulk of the pus is in the first glass, if the 
urine be voided into two glasses. 



CLINICAL NOTES ON PYURIA. 

1. Pigmented pus corpuscles justify a diagnosis of 
chronic catarrhal cystitis. (Heitzmann). 

2. Pus corpuscles with delicate red-brown haema- 
toidin crystals in them signify previous haemorrhage, 
as in the tubules or pelvis of the kidneys. (Heitz- 
mann). 

3. In chronic abscess of the kidney large quantities 
of hasmatoidin may be mixed with the pus. (Heitz- 
mann). 

4. In diseases affecting the renal parenchyma the 
amount of pus, as a rule, is small, except when a large 
abscess, located in the kidney structure proper, has 
suddenly burst into the renal pelvis. 

5. Pus corpuscles are more abundant in the urine of 
acute nephritis than in that of chronic. 

6. In the course of well- recognized chronic nephritis 



PUS CORPUSCLES IN URINE. 



297 



an increase in the number of pus corpuscles indicates 
either an acute intercurrent nephritis or a complicat- 
ing pyelitis, ureteritis, or cystitis. 

7. In cases of simple renal hyperemia pus corpuscles 
are never abundant. 

8. As a rule the sudden appearance of a large 










©*£* 



Fig. 73. 



Diagram of pus corpuscles of persons of different 

constitutions. 



E, Pus corpuscle of an excellent constitution; the bioplasm nearly- 
compact, containing a few small vacuoles, alive in a, alive 
and contracted in b, dead and contracted in c. G, Pus cor- 
puscle of a good constitution, the bioplasm coarsely granular, 
alive in a, alive and contracted in b, dead and contracted in 
c. If, Pus corpuscle of a middling good constitution; the 
bioplasm less coarse, with a compact nucleus, alive in a, 
amoeboid in 6, dead in c. P, Pus corpuscle of a poor consti- 
tution; the bioplasm comparatively scarce, finely granular, 
vesicular nuclei very distinct; alive in a, amoeboid in b, dead 
and burst in c. 

Series P, indicates a broken-down constitution and rapidly ap- 
proaching death. 

Note:— Jagged forms of pus corpuscles found on drying, or 
evaporation of the highly ammomacal urine of chronic cystitis, 
should not be mistaken for a result of amoeboid motion. 

38 



298 URINARY ANALYSIS. 

quantity of pus in urine, previously normal or nearly, 
may most always be referred to the rupture of a neigh- 
boring abscess into the urinary passages. 

9. Heitzmann holds that the constitution of an indi- 
vidual may be told by study of the pus corpuscles in 
his urine. Fig. 73 illustrates his idea. 

10. When pus is from the kidneys, free oil may 
sometimes be found, when casts are absent. In a 
recent case, confirmed by operation on the kidney, the 
writer found abundance of free oil by sedimenting the 
pus in the centrifuge, at a speed of 1,000 revolutions, 
decanting the supernatant urine, and sedimenting this 
at a speed of 1,700 revolutions. 

11. Catheterization of the ureters is a most useful 
process for determining the locality whence pus is 
derived. 

12. In posterior urethritis if the urine is voided into 
two glasses the urine in the first glass will always be 
cloudy, but that in the second will sometimes be clear, 
sometimes cloudy, while the urine is acid in reaction. 

MUCOUS COKPUSCLES. 

These resemble pus corpuscles but are irregular in 
size and in shape, have no nucleus but are granular; 
they are less compact than the pus, and are more like 
collections of fine granules. 

MICROSCOPICAL EXERCISE IV. 

1. Examine blood corpuscles (a) in acid urine, (h) in 
urine which has stood for some time, and (c) in urine 
diluted with water. 

2. Examine pus corpuscles (a) in acid urine, (b) in 
alkaline urine or urine diluted with water, (c) in 
strongly ammoniacal stale urine. 

3. To a field of pus corpuscles of the usual globular 
form add a drop of acetic acid, and note effect on nuclei. 

4. Obtain, if possible, pus from an old case of pyel- 
itis and note microscopical appearance of corpuscles. 

5. Sediment pus in centrifuge at 1,000 revolutions 
for 5 minutes; decant, sediment decanted portion at 
1,700, and look for oil. 



EPITHELIUM IN URINE. 299 



CHAPTEK XLYII. 



EPITHELIUM IN URINE. 

Epithelium, the normal product of mucous surfaces, 
in greater or less amount occurs in nearly all urine, 
and is exceedingly abundant in the urine of women, 
when it forms a whitish flocculent sediment. 

Whether diagnosis can be made with certainty by 
identification of epithelium is a disputed point. The 
late Charles Heitzmann, one of the ablest pathologists 
in this country, was emphatic in his opinion as to the 
possibility of recognition of the locality whence epi- 
thelium was derived. He proved his own ability to 
do so in several instances, when urine was referred to 
him by the writer, from cases the symptoms and his- 
tory of which were known to me but unknown to 
him. There is not a shadow of doubt in my own 
mind about Heitzmann's ability to make diagnoses 
from observation of what other writers are loth to 
recognize as significant. 

The epithelia found in urine are shown in the fol- 
lowing, Figure 74, taken from Heitzmann : 

SIGNIFICANCE OF EPITHELIA. 

In urine of males: — 

1. The largest columnar epithelia from the urethra occur in 
deeply seated bbnorrhceic inflammation, and in ulcerations 
which often lead to formation of a stricture. 

2. Cuboidal epithelia, somewhat smaller than the average cu- 
boidal epithelia of the bladder, come from the prostate in catar- 
rhal prostatitis ( oung men), and hypertrophy of the prostate 
(men c>> <-r 40). 

3 (ilia fed columnar epithelia, distinctly surpassing in size 
those from the mucosa of the uterus, indicate slight catarrhal 
inflammation of the ejaculatory ducts. They are rarely seen cili- 
ated, as the cilia break off very easily; delicate parallel rods in 
the interior indicate original ciliation. 
In urine of females: — 

1. Large, flat, vaginal epithelia indicate catarrhal vaginitis. 
The largest cuboidal and columnar epithelia are observed in cases 
of intense, deeply-seated, or ulcerative vaginitis. 



300 



URINARY ANALYSIS. 
DM 




Fig. 74. Epithelia found in urine. 

B, Bladder epithelia from upper layers; BM, bladder epithelia 
from middle layers; BD, bladder epithelia from the deepest 
layer; P, prostatic epithelia; E, epithelia from the ejaculatory 
ducts; V, vaginal epithelia from upper layers; VM, vaginal 
epithelia from middle layers; VD, vaginal epithelia from the 
deepest layer; C, epithelia of the cervix uteri; U, epithelia of 
the mucosa of the uterus; PK, epithelia from pelvis of the 
kidney; KC, kidney epithelia from the convoluted tubules; 
KS, kidney epithelia from the straight collecting tubules. 
Magnified 500 diameters. (Heitzmann). Bartholinian epi- 
thelium corresponds to prostatic. 



EPITHELIUM IN URINE. 301 

2. Flat cuboidal epithelia (smaller in size than vaginal and as a 
rule fiuplv granular, often with offshoots) are found, together with 
pus and blood corpuscles and shreds of connective tissue, in ulcer- 
ation of the cervix uteri. 

Note:— Coboidal epithelia are originally angular, polyhedral formations, but, 
by eweliing in the urioe, they assume a more or less regular or even perfectly 
spherical form. 

3. Delicate, columnar, ciliated epithelia from the mucosa of the 
uterus, accompanied by ciliated pus corpuscles, indicate catarrhal 
endometritis. 

In urine of both sexes: — 

1. Flat epithelia of the bladder, in small numbers and without 
pus corpuscles, are normal. 

2. Flat epithelia in larger amount (with pus corpuscles and epi- 
thelia from middle layers of the bladder, exhibiting endogenous 
new formation of pus corpuscles) indicate acute catarrhal cystitis. 

3. If the cuboidal epithelia largely outnumber the flat, or are 
scanty in comparison with the large amount of pus corpuscles, 
and especially if some pus corpuscles contain dark-brown pigment 
granules, the case is one of chronic cystitis. 

4. Clusters of uric acid crystals in freshly voided urine, together 
with caudate epithelia somewhat smaller than those of the mid- 
dle layers of the bladder, indicate deposit of uric acid in the pelvis 
of the kidney. 

5. Pelvic epithelia, together with epithelia from the uriniferous 
tubules, indicate pyelo-nephritis. 

6. Pelvic epithelia with red blood corpuscles, and shreds of con- 
nective tissue, indicate hemorrhage and ulceration in the kidney 
pelvis. 

7. Renal epithelia, together with pus corpuscles, signify catar- 
rhal (interstitial) nephritis. 

8. Renal epithelia, together with pus corpuscles and tube-casts, 
signify croupous (parenchymatous nephritis). 

9. The same with large quantities of pus corpuscles signify sup- 
purative nephritis. 

EPIDERMAL SCALES. 

These are irregular in size and in shape and some- 
what resemble epithelia, but are without nucleus. 
They are of no significance. 



MICROSCOPICAL EXERCISE V. 

1. Obtain the urine of a woman who has borne 
children, and study the white sediment of vaginal 
epithelia. Note epithelia from upper and middle 
layers in cases where leucorrhoea exists. Note also 
pus corpuscles. (Fig. 75). 



30. 



USINA JRY A KA L Y&I6. 



& 






* 




* 



Fig. 75. Sediment comrnon ir ,„,w of women; vaginal epithelia 
duu ucons. (-rnoto-uiicrograph). 

2 Obtain urine from the same woman voided after 
a cleansing vaginal injection, or drawn off bv the 
catheter, and note smaller quantity of epithelia and 
absence of pus corpuscles. 

3. Let the urine, obtained as in 1, stand in a cold 
place until urates have deposited, and notice how they 
hide the epithelia. ' 

4. Obtain the urine from a case of cystitis and 
demonstrate pus corpuscles and epithelia from the 
middle layers of the bladder. Demonstrate prostatic 
epithelia m the urine of old men with enlarged p r0S - 

5. If possible, obtain urine from a case of suppura- 
tive nephritis and pyelitis, and demonstrate renal and 
pelvic epithelia. 

6. Obtain urine from a man who has the so-called 
clap-threads in the urine and study their appear- 
ance. Ot what are they com posed ? 



TUBE-CASTS IN URINE. 808 



CHAPTER XLVIII. 



TUBE-CASTS IN THE URINE. 

Casts are in all probability composed of the coagu- 
lable elements of the blood which, after gaining access 
to the renal tubules, entangle in them any free or 
partly-detached products of the tubules, and form 
molds of the latter. The substance of which they are 
composed is a proteid not identical with any that we 
recognize. 

Tube-casts proper consist of a uniform, transparent, 
gelatinous matrix to which other elements (epithelia, 
corpuscles, and even various salts, both crystalline and 
amorphous) may be accidentally attached. 

They must be distinguished from (a) cast-like forma- 
tions, i. e., groupings of salts, corpuscles, etc., which 
lack uniform matrix, and (b) the band-like formations 
known as cylindroids and mucous cylinders. 

IDENTIFICATION OF OASTS. 

• 

Study Figures 76, 77 and 78. 

1. Casts should be sought for with a low power and 
without cover-glass. The urine should be acid. 
Alkaline urine rapidly dissolves casts. 

2. They may be recognized by use of a power of 
150 diameters, when they will look small, yet much 
larger than corpuscles, spermatozoa bacteria, or small 
crystals, as oxalate. 

3. They are of uniform breadth, and usually longer 
than they are broad. 

4. They have usually at least one well-rounded 
extremity, and well-defined borders. 

5. They are not longitudinally striated, not jagged, 
nor provided with processes, not jointed, segmented, 
nor serrated. They may possibly be spirally twisted 
at one or both ends. 



304 URINAR Y ANAL YSIS. 

6. They are distinguished from large epithelia by 
absence of the nucleus, and by the well-rounded ex- 
tremity. They refract, also, differently. 

7. They are distinguished from bacteria, corpuscles, 
spermatozoa, and oxalate crystals by their larger size, 
uniform breadth, greater length than breadth, and 
rounded extremity. 

8. They are distinguished from large crystals by 
absence of geometrical form and less refraction. 

9. In some cases one end of the cast tapers off con- 
siderably, and presents a spirally twisted appearance, 
which may go on to such an extent that the entire 
cast becomes transversely striated. Broad hyaline 
casts may sometimes be branched dichotomously at 
one end. 

10. Their kind must be determined by use of a high 
power, 500 diameters. 

11. To find hyaline casts tilt the mirror of the 
microscope, so as to darken the field gradually, when 
the outlines or shadows of delicate hyaline casts may 
be seen, which otherwise might escape detection. 

KINDS OF OASTS. 

Hyaline casts: — These are colorless, usually very pale, trans- 

Earent, and readily soluble in acetic acid, a fact which must be 
orne in mind, when this reagent is added to a sediment in order 




Fig. 76. Hyaline casts. (Simon). 



TUBE-CASTS IN URINE. 



305 



to dissolve phosphates. Small granules may almost always be 
seen imbedded in or adhering to their matrix. In breadth these 
casts are usually between O.Oi and 0.05 m.m. ; in length they vary 
greatly, in some cases being not much longer than they are wide, 
but in others extending across the entire microscopic field. 

It has often been said that it is impossible to reproduce hyaline 
casts in cuts so that they appear at all natural. The writer 
thinks, however, that figure 76, taken from C. E. Simon, is an 
excellent representation of them, barring the borders, which in- 
stead of being dotted should be continuous, as in Figure 77. 






Fig. 77. Hyaline, epithelial, and blood casts, seen with a high 

power. 
The series a shows casts from convoluted tubules of the second 
order; the series 6, casts from the narrow portion of the loop- 
tubules; the series c, casts from the straight collecting tubes. 
H, hyaline casts; E, epithelial casts; B, blood casts. Magni- 
fied 500 diameters. (After Heitzmann). 
39 



306 



URINARY ANALYSIS. 



Epithelial casts: —These have the hyaline matrix more or less 
concealed by epithelia. Close observation will usually show a fine 
boundary line at some portion of the structure, even when epi- 
thelia are very numerous, and a drop of acetic acid serves to dis- 
solve the matrix and set the epithelia free. 

Blood casts and pus casts:— These consist of the hyaline matrix 
with blood corpuscles or pus corpuscles imbedded in or adhering 
to the matrix. Pus casts are exceedingly rare and no cuts of 
them appear in the majority of our text-books. In a recent case 
observed by the author, in which operation disclosed pus in one 
kidney, several pus casts were found in the urine. 







Fig. 78. Granular, fatty, and waxy tube-casts, seen with a high 

power. 

The series a shows casts from convoluted tubules of the second 
order; the series b, casts from the narrow portion of the loop- 
tubules; the series c, casts from the straight collecting tubules. 
G, granular casts; F, fatty casts; W, waxy casts. Magnified 
500 diameters. (After Heitzmann). 



TUBE-CASTS IN URINE. 307 

Granular casts: — These have the hyaline matrix, and well- 
defined boundary with granular matter imbedded in or adhering 
to the matrix. Granular casts are of several kinds, as finely 
granular, or coarsely granular. The latter are usually of more 
serious significance. Coarsely granular casts may at times be 
very long, large, and dark in color, especially in rapidly fatal 
cases. 

Fatty casts: — These have the hyaline matrix dotted with fat 
granules. Free fat is usually also discoverable in the field. 

Waxy casts: — These are strongly refractive of light, have a 
yellow or yellow-gray color, and are but slowly attacked by acetic 
acid, if at all. As a rule only small fragments of them occur, but 
these are broad and stout. They may be coated with urates, or 
may contain crystals of calcium oxalate, etc., but do not com- 
monly present these features. Some of these waxy casts give the 
amyloid, reaction, that is, assume a mahogany color when treated 
with a dilute solution of iodo-potassic iodide, turning to dirty 
violet on addition of dilute sulphuric acid, but this is not patho- 
gnomic, as formerly supposed, of amyloid kidney, but due prob- 
ably to degeneration, due to long stay in the uriniferous tubules. 

OAST-LIKE FORMATIONS. 

These are composed of various elements having the cast form, 
but lacking the matrix soluble in acetic acid. 

Amorphous urates may occur simulating granu- 
lar casts in form (Fig. 79). $* T 

Bacteria may be grouped in a cast-like manner, p*§ 
but close inspection shows irregular outline, and ^J£ 
abundance of groupings not in cast form. 

Hozmatoidin and granular detritus may also 
assume the cast form. 

Epithelia may be found in cast form. Such 
formations are hollow, being thrown off en masse 
from the uriniferous tubules. Seen only in par- 
enchymatous nephritis. " " '"" 

Blood corpuscles enmeshed in fibrin are common J; IG ' ,T~.* 
in renal haemorrhages, and may assume the cast „ ^ast-like 
f orm formations of 

The differential diagnosis between a true cast amorphous 
and a cast-like formation can be made by addition urates, 
of a drop of acetic acid, which dissolves the hyaline matrix of a 
+.rue cast, but has no effect on a cast-like formation. 

CYLINDROIDS AND MUCOUS CYLINDERS. 

Cylindroids have the appearance of hyaline tube-casts, but are 
very large and band-like. They have uniform breadth and often 
contain crystals, epithelia, and corpuscles. They are soluble in 
acetic acid. They are of renal origin. True casts are sometimes 
seen, which terminate at one or both ends in cylindroids. 

Mucous cylinders are never of uniform breadth, seldom or never 
contain morphologic or mineral constituents, and are insoluble in 
acetic acid. They are found in any urine containing abundance 
of mucus, and are of no other significance. 




808 



URINARY ANALYSIS. 




Fig. 80. a and b, cylindroids. (Jaksch). 



EXTRANEOUS OBJECTS SOMEWHAT RESEMBLING OASTS. 

These are very numerous and may be divided into 
fibers, wool, feathers, and fungi, as mycelium, lepto- 
thrix, and bacteria. Figure 81, from Heitzmann, 
shows the most common ones found in urine. 

Cotton fibers are wavy and twisted with edges more compact 
than the centre is. 

Linen fibers are straight, composed of smaller fibrilla, with 
breaks and breaches from hackeling. 



TUBE-CASTS IN URINE. 



Sheep's wool has fine serrations along the edges; cuticle on sur- 
face is imbricated. 

The mycelium, especially of penicillium glaucum, is very com- 
mon in urine; with a high power it appears segmented as in the 
figure — . 

Leptothrix is small and very slender. 

Bacteria are very small, and cannot be easily recognized with 
150 diameters. 




Fig. 81. Accidental occurrences in the %ediment of urine. 

S, Silk fibers; C, cotton fibers; L, linen fibers; W, sheep's wool; 
F, feather; St, starch -granules of rice; Cr, cork particles; O, 
oidium, the seed of mildew; M, mycelium of mildew; Jfc, 
micrococci; B, bacteria; Lt, leptothrix. Magnified 500 diam- 
eters. (After Heitzmann). 



310 URINARY ANALYSIS. 

ZoogJcea masses of bacteria, exceedingly common in the urine 
of women, are often mistaken for granular casts by beginners. 
They have no matrix, are irregular in outline, and occur in great 
abundance without definite shape. 



SIGNIFICANCE OF CASTS, 

1. The writer finds that with the centrifugal ma- 
chine a few casts may be found in 1 out of every 3 
specimens of the 24 hours' urine examined. Such 
casts are usually 2 or 3 small hyaline, or 1 or 2 small 
granular, per sediment of 15 c.c. urine. 

2. In cases in which stimuli, as severe exercise, 
cold baths, etc., occasion albuminuria, casts may also 
be found. 

3. "When casts and albuminuria occur together, it 
may be assumed that the albuminuria is renal. 

4. Albuminuria and a few hyaline casts, especially 
if latter are only temporarily present, signify a mild 
circulatory disturbance of the kidneys. 

5. Continuous presence of hyaline casts in abund- 
ance, together with albuminuria, especially if marked, 
indicates the existence of a nephritis. 

6. Numerous hyaline, epithelial, and blood casts 
signify acute croupous (parenchymatous) nephritis. 
{Heitzmann). 

7. Numerous granular, fatty, and waxy casts sig- 
nify chronic croupous (parenchymatous) nephritis. 
{Heitzmann). 

8. Casts of both acute and chronic forms indicate a 
subacute form, chronic inflammation with acute recur- 
rences. {Heitzmann). 

9. The greater the number of casts, the more seri- 
ous the nephritis. {Heitzmann). 

10. A large number of blood casts in the urine of 
adults indicates a fatal termination in a short period of 
time. {Heitzmann). 

11. The size of the casts is of great prognostic value 
(Fig. 77). Narrow casts together with a small number 
of casts of medium width, signify a mild degree of 
nephritis. Casts of medium width denote inflamma- 
tion of the cortical substance. Casts of all three sizes. 






TUBE-CASTS IN URINE. 311 

the largest arising from the straight collecting tubules, 
signify inflammation in the whole organ, in which case 
there is a very unfavorable prognosis. {Heitzmann). 

12. Hyaline casts studded with fine granules may 
be called "verging on granular," and indicate an 
incipient chronic nephritis as in third or fourth week 
of scarlet fever. When casts have distinct outlines 
they are ' 'verging on waxy, ' ' as granular- waxy , fatty- 
waxy. Epithelial casts may be "verging on fatty and 
waxy," either or both. Hyaline, epithelial, fatty, 
and granular casts have indistinct outlines, but when 
verging on waxy the outlines are distinct. Fatty 
casts may be told from casts of cocci by their glossy, 
distinct granules; cocci are smaller, sharply defined, 
as in zoogloea, and darker. Fat granules are larger, 
less sharply defined, and not so dark. (Heitzmanri). 

13. Fatty casts are most commonly associated with 
subacute or chronic inflammations of the kidney of 
protracted course, with tendency to fatty degeneration 
of the renal tissues. (Jaksch). 

14. Epithelia found in tube-casts, if shrunken and 
atrophic, indicate an inflammatory renal process com- 
plicated with degenerative changes. Epithelial casts 
without presence of distinct changes affecting the 
renal parenchyma are probably never seen. 

15. Pus corpuscles in small numbers on hyaline 
casts are common in various nephrites, especially in 
acute cases. 

16. Pus-casts indicate suppurative inflammation of 
the kidneys. 

17. Cylindroids accompany hyaline casts, and are of 
the same significance. 



312 URINARY ANALYSIS. 



THE WRITER'S OBSERVATIONS ON MORTALITY IN ALBUMINURIA WITH 
AND WITHOUT CYLINDRURIA. 

In an article in the New York Medical Times, July, 1895, the 
writer gave the statistics of mortality in 500 cases of albuminuria 
as follows: 

SUMMARY NO. 1. 1888-1895. 

I. Non-albuminuric cases whose present condition is known 

with certainty 253 

Deaths 28 

Percentage of mortality thus far 11 

II. Albuminurics without casts 255 

Deaths 37 

Mortality per cent thus far 14 

III. Albuminurics with casts 304 

Deatbs 89 

Percentage of mortality thus far, about 30 

SUMMARY NO. 3. 

I. Albuminurics with casts. 304 

Without granular, fatty, or waxy casts 177 

Deaths 36 

Percentage of mortality thus far — 20 

II. "With granular, fatty, or waxy casts 127 

Deaths 53 

Percentage of mortality thus far 41 

III. Mortality in those of II, according to sex: 

(a) Total number of men 93 

Deaths 37 

Percentage of mortality thus far 40 

(6) Total number of women 34 

Deaths 16 

Percentage of mortality thus far 47 

From these figures it will be seen (1) that the death-rate was 
greater among those who had albuminuria without casts than 
among those who had no albuminuria at all, and (2) that the 
death-rate among those who had albuminuria with casts was 
greater than in those without casts, while (3) the death-rate of 
those albuminurics with granular, fatty, or waxy casts was double 
that of those with only hyaline, epithelial, or blood casts. 



TUBE-CASTS IN URINE. 
MICROSCOPICAL EXERCISE VI. 



313 



1. Obtain the urine of a patient with post-scarla- 
tinal nephritis and study the different kinds of tube- 
casts. Notice in a severe case the large number of 
objects in the field and the variety of them, not less 
than four different constituents being present in 
abundance. -(Fig. 82). 




Fig. 82. The field in nephritis. (Photo-micrograph). Note tube- 
casts, corpuscles, epithelia, etc. 

2. Obtain the urine from a case of chronic nephritis, 
preferably with dropsy and high-colored, scanty, albu- 
minous urine, and study the casts. What are the pre- 
vailing ones? 

3. Obtain the urine of a man over 40 with chronic 
interstitial nephritis and look for casts? Are they 
numerous? What kind? 

4. Add dust from the dustpan to a sample of nor- 
mal urine and study the sediment for extraneous 
objects. 



314 



URINARY ANALYSIS. 



CHAPTER XLIX. 



SPERMATOZOA, 



CONNECTIVE TISSUE, 
ISMS, PARASITES. 



MICRO-ORGAN- 




Fig. 83. Spermatozoa. 

as in cystitis, 



Spermatozoa: — (Fig. 83), 
are found in the urine of 
healthy adults after pollu- 
tions or coitus and are then 
of no significance. 

Constant presence of sper- 
matozoa in the urine is noted 
in spermatorrhoea due to 
sexual excesses or masturba- 
tion. 

In cases in which semen 
is passed during defecation 
or from irritation of ammoniacal urine, 
no deleterious effects seem to appear. 

Spermatozoa are found in the urine after epileptic 
seizures and sometimes after hystero-epileptic attacks ; 
also in certain spinal diseases, and in severe illness as 
typhoid. 

In the urine spermatozoa are almost always quies- 
cent; they are in form thread-like bodies provided 
with a head and a long, tapering, tail-like extremity. 
The entire length is about 1-600 of an inch and they 
must be searched for with a high power. 

Connective tissue: — Little is to be found in medical literature 
regarding this substance in the urine, except what has been writ- 
ten by Heitzmann. The appearance of connective tissue fibers in 
the urine is a frequent phenomenon. They are, as a rule, small 
and are distinguished from mucous threads by their greater 
refraction, their almost invariable occurrence in bundles of vary- 
ing size, their fibrillary or finely granular appearance, and of the 
presence in them at times of formations similar to nuclei. Linen 
fibers possess strong refraction but split in a way essentially dif- 
ferent from connective tissue. 



CONNECTIVE TISSUE IN URINE. 



315 



Shreds of connective tissue are found in the urine in: 

1. Ulcerations. 

2. Abscesses. 

3. Tumors. 

4. HEemorrhages. 

5. Trauma. 

6. Cirrhosis and atrophy of the kidneys. 

7. Hypertrophy of the prostate. 

Connective tissue studded with fat is probably from the kidneys. 

Figure 84, a photo-micrograph, by Dr. Charles Gordon Fuller, 

of Chicago, from one of the writer's slides obtained from Dr. 




Fig. 84. Shred of connective tissue in urine of a case of tumor of 
the bladder. Photo-micrograph by Dr. Charles Gordon Fuller, 
of Chicago. 

Heitzmann, shows a shred of connective tissue found in the case 
of a tumor of the bladder. 

When tumors are present in the urinary tract, connective tissue 
is most abundant. If papilloma of the mucous membrane of the 
bladder exist, there will be found, especially on diluting the urine 
with water and sedimenting with the centrifuge, much elongated 
shreds of connective tissue, which, under the microscope, appear 
spread out like branches, knotted or convoluted, shriveled, and 
containing blood vessels in which are but few inflammatory cor- 
puscles and no epithelium-nests. 

Micro-organisms:— Healthy urine is an aseptic fluid which, on 
standing exposed to the air, soon contains great numbers of micro- 



316 URINARY ANALYSIS. 

organisms. Abnormal urine nearly always contains micro-organ- 
isms: These are fungi, pathogenic and non-pathogenic. Non- 
pathogenic fungi are molds, yeasts, and fission-fungi. Molds are 
found on the surface of old saccharine urine which has undergone 
alcoholic fermentation, or less frequently on the surface of putrid 
urines containing no sugar. (See Fig. — ). 

The yeast plants (saccharomyces urinse) are found in acid urine 
and abundantly in saccharine urine. The sporules occur as small 
roundish bodies (Fig. — ). suggesting blood corpuscles in size and 
shape, but are irregular, sometimes of large size with nuclei, and 
are more elongated or oval. They are often arranged in bead-like 
forms, some of which may have several small bud-like bodies 
attached to them. In great numbers they are indicative of pres- 
ence of sugar. 

Fission fungi are found as the urine begins to putrefy; it is then 
cloudy, not easily filtered clear, never sharply acid, and usually 
neutral or feebly alkaline. Such urine is common in the case of 
delicate women and in men with stricture or who use catheters 
or bougies. The fungi in these conditions are the micrococcus 
urese (Fig. 85), and various rod-like bacteria; occasionally long 
spiral bacilli with large spores and cocci occur. Nearly all these 
microbes possess the power to transform urea into ammonium 
carbonate. 




Fig. 85. Micrococcus urese. 

The micrococcus urese accurs in almost pure culture on the sur- 
face of fermenting urine in the form mostly of characteristic 
chains as in the figure. The individual coccus is large and is 
sometimes mistaken for a blood-shadow or "ghost." The diag- 
nosis of ammoniacal fermentation within should not be made 
unless the presence of ammonia can be demonstrated in freshly 
voided urine, as some urines undergo fermentation, particularly 
in warm weather, shortly after being voided, and especially if the 
vessel employed is not absolutely clean. 

Sarcinae (Fig. 86) occur in urine and are ^ 

smaller than those found in the stomach, & 
being in point of size comparable to those $ £ 
of the lung. The writer has noticed them 
particularly abundant in a case of chronic 
cystitis occurring in a patient with paraly- ® 

sis agitaus. ^ e 

Pathogenic fungi are numerous and be- & s o 

long to two orders, micrococci and bacilli. ^ 

In suppurative diseases we find the char- 
acteristic micrococci as the staphylococcus _ @ 
pyogenes albus, aureus, citreus, and the f* • 

streptococcus pyogenes. The bacilli found % « 

include the bacillus coli communis the uro- „ „„ 

bacillus liquefaciens septicus, the bacillus . * . °* . 
tuberculosis, and many others. As a gen- Sarcinae .11 urine, 
eral rule the organisms causing the morbid processes are elimi- 



BACTERIA IN URINE. 317 

nated. Pathogenic organisms have been found in the urine in 
erysipleas, measles, scarlatina, relapsing fever, sepsis, typhoid 
fever, tuberculosis, etc., but unfortunately it is only exceptionally 
that the diagnosis of specified fevers can be made by bacteriologic 
examination of the urine. 

Even the search for the tubercle bacillus in the urine is fre- 
quently fruitless. By use of Dr. Purdy's small tubes, designed for 
sedimentation of bacteria, and a high speed, 5000 or more revolu- 
tions per minute, of the centrifuge one is more likely to find the 
tubercle bacillus, which should always thus be sought for in the 
case of pyuria accompanied by anaemia, wasting, and evening 
temperature. The urine must be obtained with the catheter to 
avoid admixture with the urine of smegma bacilli which can be 
with difficulty distinguished from the tubercle bacilli. Injection 
of a few drops of the sediment of such urine into the anterior 
chamber of the eye of a rabbit; the urine being obtained under 
bacteriologic precautions, is advisable, the development of miliary 
tubercles of the iris being watched for. The search for the bacil- 
lus is made as in sputum and should only be undertaken by an 
expert. Those not familiar with bacteriology do not realize the 
care and experience necessary in this operation. 

The relation of micro-organisms to nephritis is now occupying 
the minds of a number of observers and some interesting studies 
have been made, as for example, of the role of the bacillus coli 
communis. In general, however, nephritis is referable to ptomain 
intoxication rather than to the action of bacteria, although their 
presence in the kidneys may be regarded as indicating the exist- 
ence of some definite alteration of the renal parenchyma. 

Non-pathogenic bacteriuria has occasionally been noticed but 
the occurrence is very rare and possibly not associated with any 
pathologic condition, although the bacillus coli communis has 
been obtained in pure culture from cases of pyelitis. 

Gonococci may be found in the cellular elements in urinary sedi- 
ments, but in making the examination for them a drop of the 
discharge should be taken from the meatus on a cover-glass, 
spread out in as thin a layer as possible, allowed to dry, 
passed three or four times through the flame of a Bunsen, and 
stained with a drop of carbol fuchsin without application of heat. 
Excess of coloring matter is removed by rinsing in water, the 
specimen is dried between layers of filter-paper mounted in a drop 
of water and examined, preferably with an oil immersion lens. 
The gonococci consist of minute roll-shaped cocci, chiefly met 
with as diplococci, the individual cocci being seemingly divided 
by a bright, transverse band often presenting the so-called roll 
form; also called the kidney or bean shape. The cocci usually 
appear in pairs lying close together, their flattened surfaces usu- 
ally presented to each other. Presence of gonococci within the 
cellular elements is deemed characteristic. The reader is referred 
to works on Bacteriology for figures. 

Animal parasites: — The ova of distoma haematobium and the 
filaria sanguinis hominis occur in the urine. The parasites cause 
various serious urinary diseases, as hydronephrosis, pyonephrosis, 
pyelitis, and pyelonephritis, and the ova serve as nuclei for stone. 
Echinococcus. ascarides, strongylus gigas, and infusoria are also 
found. Filaria are found in our Southern States, and cause chy- 
luria. The eggs of distoma are oval, flask-shaped bodies. 



31b URINARY ANALYSIS. 



CHAPTER L. 

THE URINE AND CHARACTERISTIC SYMPTOMS OF DIS- 
EASES OF THE KIDNEYS. 

The following pages show the clinical features of 
the most common urinary diseases : 

Acute renal hyperemia {active congestion): — 

Frequency, urgency, possibly vesical tenesmus. Urine contains 
less than 10 per cent bulk of albumin, a few hyaline casts, and 
perhaps a little blood. Suppression possible. 
Chronic renal hyperemia {passive congestion): — 

Cardiac symptoms, dropsy, dyspnoea, cyanosis (not in milder 
cases); weak, thready pulse; hacking cough. Urine decreased in 
quantity, specific gravity increased, albumin small, casts few, 
hyaline; urates and mucus. 
Acute diffuse nephritis {including post-scarlatinal nephritis):— 

Dropsy, pallor, high pulse and temperature, nausea, vomiting, 
headache, stupor, coma, convulsions. Blood the urinary feature. 
Albumin abundant, numerous hyaline, epithelial, and blood casts; 
later, granular and perhaps fatty casts. 

Chronic diffuse nephritis {including parenchymatous or croup- 
ous, formerly so-called) : — 

Obstinate dropsy, anaemia, pallor and puffiness of face, debility 
and loss of flesh. Night urine exceeds day. Albumin abundant. 
Dark granular, fatty, and waxy casts. Later, urine more abund- 
ant, lighter in color, less albumin. 

Chronic interstitial nephritis {contracting kidney, terminating 
in cirrhosis): — 

Rising at night to urinate; full, hard 
pulse; displacement of apex beat of 
heart, accentuation of second sound (at 
second right intercostal space, one-half 
inch from the sternum), retinitis, post- 
cervical neuralgia, dizziness, drowsiness, 
coma, convulsions. Slow course, sudden 
death. Polyuria. Deficiency of phos- 
phoric acid marked. Trace of albumin, 
increased at times. Casts, few hyaline. 
Night urine equals or exceeds day. 

Note: — The kidneys finally become 
contracted, small, and hard. The actual 
size possible is shown in figure 87. 
Lardaceous disease {amyloid disease):— Fig. 87. Cirrhotic 

Gastro-intestinal symptoms the fea- kidney, actual size, 
ture; diarrhoea. Sallow complexion. {McNutt). 

History of syphilis or suppurations. Tuberculous family history. 
Dropsy. Enlarged spleen and liver. Albumin abundant; casts 
not abundant, large hyaline or waxy. 




CHARACTERISTIC SYMPTOMS. 



319 



Cystic disease of kidneys: — 

Cardiac symptoms of chronic interstitial nephritis. Soft, non- 
fluctuant, kidney-shaped, bilateral renal tumor of slow growth. 
Urine of chronic interstitial nephritis, plus blood; more albumin 
and large granular casts. Cystitis may complicate, with pyuria. 

Puerperal nephritis:— 

Headache, visual troubles, dizziness, nausea, vomiting, convul- 
sions. Urine suddenly becomes scanty, urea suddenly increases 
in grains per ounce (12 to 14), albumin jumps from a trace to a 
large quantity, in twenty-four hours or less; casts present, not 
always abundant unless patient previously have chronic nephritis. 



DIAGNOSTIC DIFFERENTIATION. 

Chronic renal hyperemia is to be differentiated from chronic 
interstitial nephritis as follows: — 

THE URINE IN 
CHRONIC RENAL HYPEREMIA, CHRONIC INTERSTITIAL NEPHRITIS, 



Oliguria; 

Solids increased in grains 

per ounce; 
Color increased ; 
Albumin small; 
Casts few, hyaline; 
Urates and uric acid in sediment; 
Usually blood corpuscles in 

sediment. 



Polyuria; 

Solids decreased in grains 

per ounce; 
Color decreased; 
Albumin small; 
Casts few, hyaline; 
No crystalline sediment; 
Usually no blood unless cystic 



THE SYMPTOMS OF 
CHRONIC RENAL HYPEREMIA, CHRONIC INTERSTITIAL NEPHRITIS, 



Valvular diseases; 
No hypertrophy of heart; 
Weak thready pulse; 
Dropsy, chiefly of lower 

extremities; 
No uraemia; 

No rising at night to urinate; 
No visual disorders. 



No valvular diseases; 
Hypertrophy of heart; 
Full hard pulse; 
No dropsy till late; 

Chronic uraemia; 

Nocturnal micturition common; 

Visual disorders. 



Chronic diffuse nephritis must be differentiated from lardaceous 
(amyloid) disease. 



THE URINE OF 



CHRONIC DIFFUSE NEPHRITIS, 



LARDACEOUS DISEASE, 



Urinary sediment abundant; Urinary sediment scanty; 

Albumin large; Albumin large; 

Casts abundant, including dark Casts few but large size, broad 
granular and fatty; hyaline and waxy. 

Pus corpuscles, epithelia, gran- Few cellular elements. 
ular debris abundant in sedi- 
ment. 



URINARY ANALYSIS. 



THE SYMPTOMS OF 
CHRONIC DIFFUSE NEPHRITIS, LARDACEOUS DISEASE, 



Dropsy; 

Anaemia striking, pallid puffy- 
face; 

Uraemia not till late; 

Dyspepsia and diarrhoea not 
permanent; 

Liver and spleen not enlarged. 



Dropsy; 

Cachexia: — face sallow or 

bronzed; 
Uraemia rare; 
Dyspepsia and diarrhoea are 

notable features; 
Liver and spleen enlarged. 



Cystic disease of the kidneys must be differentiated from 
chronic interstitial nephritis and from renal cancer: — 



CYSTIC DISEASE. 



CHRONIC INTERSTITIAL 
NEPHRITIS. 



CANCER. 



Non-fluctuant swell- No swelling; 

ing in the sides; 

Recurrent severe No haematuria, 

haematuria; 

Slow growth of No growth; 

tumor: 

No pain; 

Sallow, cachectic ap- Patient well-pre- 

pearance; served; 

Age, 40 to 55. Age over 40. 



Nodular growth of 
unequal resistance; 

Irregular intermit- 
tent haematuria; 

Rapid growth: 

Pain; 
Emaciation and 

cachexia; 
Age under 5 or 

over 60. 




Fig. 88. Stone in the kidney. 



CHARACTERISTIC SYMPTOMS. 



321 



Renal embolism:— 

History of endocarditis; sudden renal pain, perhaps with 
repeated chills and cardiac symptoms; if renal pain severe, vom- 
iting and collapse. Sudden albuminuria gradually diminishing in 
two to four weeks; hyaline, epithelial, and leucocyte casts for a 
few days, then disappearing. 

Renal calculus: — 

Dull ache deep in loin; patient flinches on deep pressure with 
thumb over one kidney; renal colic, violent unilateral pain down 
the course of the ureter to the testicle; gastric disturbances; gen- 
eral nutrition good. Urine contains blood which is increased by 
exercise; crystals, especially sharp-pointed uric acid, and oxalate 
concretions. Figures 88 and 89 show stone in kidney. 

Renal cancer: — 

Symptoms are increasing tumor between the costal arch and 
the crest of the ilium; tabulated; nearly always fixed; pain early, 
usually persistent, sometimes intermittent; dull ache in begin- 
ning, later lancinating not affected by movements. Emaciation; 
anaemia; cachexia (brownness or sallowness of the skin); debility. 

Urine contains blood, appearing and disappearing at intervals 
without cause. Pus very small in amount, albumin corresponds 
to blood. Acetone present. Urination frequent. 



8*o, 



'"e/j, 




s tottf 



W 



CO' 



t W<* V 



Stone in pelvis. 



— Stone in ureter. 



Nephrolithiasis. 



Fig. S9. Stone in the kidney. (McNutf). 



41 



322 URINARY ANALYSIS, 

Sarcoma of kidney:— 

Microscopical diagnosis of small round-cell sarcoma: The urine 
contains: i. Pus corpuscles; 2, red blood corpuscles: 3, shreds of 
connective tissue; 4, sarcoma corpuscles, in size midway between 
red blood corpuscles and pus corpuscles, either coarsely granular 
or homogeneous, i. e., composed of compact living matter, non- 
nucleated They are larger than red blood corpuscles, and more 
granular; differ from pus in having no nucleus. The diagnosis of 
sarcoma is not possible unless ulceration of the tumor is present, 
which involves the presence both of red blood corpuscles and 
shreds of connective tissue. 
Renal tuberculosis:— 

Polyuria: dysuria prominent and increasing progressively until 
the bladder is comfortable only when empty, usually no pain at 
end of urination. More or less pain in renal region, with tender- 
ness on deep pressure. Rise of 2 to 4 degrees in the temperature 
at night; or periods of fever for several days, with periods of 
remission. Profuse night-sweats, loss of appetite, debility, loss 
of flesh, cough, and diarrhoea. 

Urine increased, traces of albumin, a few blood corpuscles, and 
pale cloudy urine, acid and of low specific gravity; followed, 
when ulceration sets in, by alkaline milky urine containing pus, 
the latter remaining in suspension even on long standing. Blood 
in 1 case out of 4, may be small, but sometimes is abundant. 
Finally, offensive ammoniacal urine, with ropy muco-pus, triple 
phosphate, cheesy masses, and with more albumin than pus and 
blood accounts for. The bacillus tuberculosis, if present, is best 
recognized by cultures in gelatin and inoculation of animals. 

Hydronephrosis: — 

Tumor in loin, sudden diminution of which corresponds with 
sue den increase in non-purulent urine which sometimes contains 
blood or blood-clots causing renal colic. 

Pyonephrosis:— 

Tumor in loin with scanty purulent urine, chills, evening tem- 
perature, debility: all symptoms relieved by copious flow of urine 
containing blood and pus. 

Acute pyelitis: — 

Accompunii s pyonephrosis and suppurative nephritis. 
Chronic pyelitis:— 

ching and d tagging lumbar pain, worse on pressure and 
exercise. Polyuria; greenish urine; odor slightly of rotten eggs; 
pus not sticky, if the urine is acid: albumin more or less abund- 
ant; pus corpuscles, with tooth-like projections; triple phosphate 
crystals in acid urine. Frequent painless micturition. 
Acute jijelo-nephrltls (Suppurative nephritis; surgical kidney): — 
Copious pyuria with constitutional symptoms: chills, high tem- 
perature, brown tongue, etc. Sediment of urine contains pus, 
blood, casts, bacteria, bacteria casts. Albumin abundant. 
Disease rapidly fatal, if both kidneys affected. 

Moyable Kidney:— 

Patient commonly a thin woman who has rapidly borne chil- 
dren. Dull, aching, dragging pain in the side with severe par- 
oxysms.. Gastro-intestinal symptoms, more or less mobile tumor 
manipulation of which causes peculiar, sinking, or fainting sensa- 
tions, or nausea. Scanty high-colored urine or short suppression 



CHARACTERISTIC SYMPTOMS. 323 

followed by short polyuria. Haematuria not infrequent. Slight 
albuminuria. Differentiation from tumors, etc. difficult. 
Cystitis {Inflammation of the Bladder): — 

Causes: — Local bladder infection by bacterial germs: hence 
many causes, as gonorrhoea, stricture, enlarged prostate, stone, 
sexual excess, etc. 

Symptoms: — Pus in the urine, frequent urination and pain 
especially after urinating. No persistent constitutional symptoms. 

The Urine: — In "acid cystitis" or more recent disease of the 
bladder, the urine is acid when voided. More turbid in the first 
glass than in the second, plainly albuminous, with flocculent pus; 
microscopically, large round epithelia from middle layers of the 
bladder, pus corpuscles, blood corpuscles, and possibly bacteria, 
with a few imperfect crystals of triple phosphate. In "alkaline 
cystitis" or older cases the color of the urine is lighter, reaction 
alkaline, odor ammoniacal or pungent or both; albumin in traces 
only, sticky pus; microscope always shows bacteria, chiefly the 
pathogenic, as bacillus coli communis and staphylococcus pyogenes 
aureus, pus corpuscles, blood corpuscles, bladder epithelia, and 
plenty of triple phosphate. 

Stone in the Bladder:— 

Symptoms:— The features are pain and interruption of mictur- 
ition The pain may be felt along urethra, at end of penis, in 
testicles, or down the thighs, is severe with spasm at close of 
micturition, worse on motion, frequency of urination is present, 
worse on motion. 

Urine: — At first urine normal in appearance with deposit of 
crystals. Later the urine of cystitis plus crystals, and blood at 
the close of micturition aggravated by motion. 

Tuberculosis of the Bladder:— 

Symptoms: — Patient 15 to 30 years old of tuberculous family; 
increased frequency of urination during the day, followed by 
hematuria and rising at night; severe tenesmus at close of mic- 
turition with constitutional symptoms of tuberculosis; evening 
temperature, night-sweats, etc. Features are relief from pain 
when bladder is empty, persistent perineal pain, pain in the mid- 
dle of the penis, haematuria without cause and not dependent on 
exercise. 

The Urine:— Pyuria; haematuria, sometimes slight, sometimes 
pronounced; finally urine of cystitis. 
Cancer of the Bladder: — 

Symptoms: — Features are pain just before the beginning of 
urination with frequency of micturition. In some cases sharp 
pain radiating to the thighs above symphysis or in perineal region. 
Haematuria. 

The Urine: — Irregular and very large shreds of connective tis- 
sue. Epithelia with very large prominent nuclei; blood; features 
of cystitis. Epithelial nests in granular connective tissue are 
suspicious and very irregular shreds with nests characteristic. 
Benign Growths of the Bladder: — 

Typical shreds, in the urine, of connective tissue of yellow 
brown color like yellow casts. Great size is characteristic, and 
more regular form than in cancer. 



324 URINARY ANALYSIS. 



MISCELLANEOUS. 

Diabetes Mellitns:— 

Polyuria; glycosuria, diaceturia; lipuria; lipaciduria, with 
emaciation, thirst, hunger, debility, nervous disorders, and sub- 
normal temperature. Pale urine of high specific gravity. 
Diabetic Comae- 
Gastric pain, dyspnoea, and drowsiness in course of diabetes 
mellitus. 

Diabetes Insipidus: — 

Great polyuria; thirst; emaciation and debility; sub-normal tem- 
perature; pale urine of low specific gravity. 
Chyluria: — 

Milky urine, which does not settle, with a pink tinge of blood, 
tending to coagulate spontaneously. Urine contains fat, fibrin 
and albumin. 

THE DIAGNOSIS OF PREGNANCY. 

Dr. Wm, B. Gray, of Richmond, Virginia, places 11 inch of 
urine in a small-sized test-tube, adds one-third its volume of mag- 
nesian fluid and lets precipitate settle 15 to 20 minutes. In preg- 
nancy the triple phosphate crystals formed by the above procedure 
differ in appearance from the normal. The normal triple phos- 
phate formed by precipitation is stellate and markedly feathery. 
Soon after conception (20 days) the crystals lose their feathery ap- 
pearance, the change beginning at the top and progressing toward 
the base. One side only may be affected, or both, leaving only 
the shaft and perhaps a few fragments, the shaft assuming a 
beaded or jointed appearance These changes are most marked 
in the early months and occur in a very large percentage of preg- 
nant women. Examine freshly voided urine. 



Note: — For pathology and treatment of these disorders see the 
author's new book, "The Clinical Features and Treatment of 
Urinary Diseases." 



Special: — The Appendix of this book on Urinary Analysis is 
published separately and contains a complete course in the quan- 
titative analysis of research work, including the Kjeldahl process 
for nitrogen, the Liebig-Pfliiger process for urea, the Ludwig-Sal- 
kowski process for uric acid, the Salkowski-Volhard process for 
chlorides, determination of the urotoxic coefficient, etc., etc. 
Also a complete method for the analysis of urinary calculi, and 
Charles Heitzmann's method of preserving and mounting urinary 
sediments. 



APPENDIX, 



This Appendix contains standard methods for quantitative deter- 
minations of the acidity of urine, urea, total nitrogen, uric acid, 
kreatinin, xanthin, paraxanthin, chlorine, sulphuric acid (pre- 
formed and conjugate sulphates), phosphoric acid, glycero-phos- 
phoric acid, oxalic acid, albumin, sugar, and the urotoxic co- 
efficient. Those engaged, in research work will appreciate the 
convenience of an arrangement by which the quantitative deter- 
minations are consecutively described, instead of being scattered 
throughout the whole of the preceding pages. In addition I have 
included Mceschel's resume of drugs which interfere with sugar 
and albumin tests, Long's methods of analysis of calculi, and 
Heitzmann's method of preserving and mounting urinary sedi- 
ments. 

At the end of the Appendix are certain tables which the author 
finds convenient for reference, and to which frequent allusion has 
been made in the clinical part of the book. 

DETERMINATION OF THE ACIDITY OF URINE. 

Solutions required are (a) phenolphthalein, i gm. in a mixture 
of 200 c.c. water and 300 c.c. alcohol, best prepared fresh for each 
determination, aud (b) decinormal potassium hydroxide solution 
made by diluting 100 c.c. of normal potassium hydroxide solution 
to 1,000 c.c. w 7 ith pure water. 

Normal potassium hydroxide solution is made as follows: Dis- 
solve 75 gm. of potassium hj^droxide in 1050 c.c. of water at 15 C. 
(6o° F. ), and fill a burette with this solution. Dissolve 0.63 gm. 
of pure oxalic acid in crystals in about 10 c.c. of water and add to 
it a few drops of phenolphthalein. Now add the potassium hy- 
droxide solution from the burette, until the oxalic acid is just 
neutralized, a faint pink tint being seen in the solution. Note the 
number of c.c. of potassium hydroxide used, and dilute the re- 
maiuder so that 10 c.c. of it will exactly neutralize 0.63 gm. of 
oxalic acid. The method of determining the total acidity of the 
urine is as follows: To 50 c.c. of urine add several drops of phe- 
nolphthalein and add decinormal potassium hydroxide solution 
until the pink color appears. Each c.c. of the potassium hy- 
droxide solution used is equivalent to 0.006285 gm. of oxalic acid. 
The total acidity of the 24 hours' normal urine averages an equiva- 
lent of 2 gm. of oxalic acid. 

Highly colored urine should first be shaken with animal char- 
coal and filtered. 

The acidity of urine at different times of the day can be deter- 
mined by this method. Since recognition of the true end reaction 
is impossible, owing to the action of the alkali employed on the 
acid sodium phosphate, a mixture of neutral and acid sodium 
phosphates resulting at first which produces an amphoteric reac- 



326 APPENDIX: Urea. 

tion, it is necessary to add slight excess of the hydroxide and the 
reading taken when the reaction has become faintly alkaline, the 
degree of acidity found being a trifle too high. 



DETERMINATION OF UREA (LIEBIG-PFLUEGER 
METHOD). 

(a). Mercuric Nitrate Solution. — Weigh out a quantity of 
pure mercury and heat in a porcelain dish with two or three 
times its weight of strong nitric acid, sp. gr. 1.42. Evaporate the 
dissolved mercury to the consistence of a thick syrup, adding 
from time to time a few drops of nitric acid to complete oxida- 
tion which is shown by cessation of red fumes. Pour the syrupy 
residue into ten times its volume of water with constant stirring. 
Let settle, pour off supernatant liquor, dissolve sediment in a few 
drops of nitric acid and add to the liquid poured off. Dilute with 
distilled water so that 71.5 gm. of mercury is contained in one 
liter of solution. 

(b). Baryta Solution. — To one volume of a cold saturated 
solution of barium nitrate add two volumes of a cold saturated 
solution of barium hydroxide. Keep in a well-stoppered bottle. 
The solution is used to precipitate phosphates and sulphates which 
interfere with the mercuric nitrate reaction. 

(c). Sodium Carbonate Solution. — Heat pure sodium carbon- 
ate in a platinum dish to low redness, weigh out 53 gm. of the 
salt thus dried, dissolve in distilled water, and dilute to one liter. 

(d). Standard Urea Solution. — Dissolve 2 gm. of pure urea 
in distilled water and dilute to make 100 c.c. 



PRELIMINARY TEST. 

1. To exactly 10 c.c. of the urea solution add 19 c.c. of mercuric 
nitrate solution. Shake, let stand a minute, filter. Wash precipi- 
tate with a little distilled water, and to the mixed filtrate and 
washings add enough of a weak solution of methyl orange to give 
a pink color. Next from a burette run in enough sodium carbon- 
ate with constant shaking until the pink changes to yellow; not 
over 1 1.5 c.c. of the alkaline solution should be required. From 
this calculate the amount needed for each c.c. of mercuric nitrate. 

2. To exactly io c.c. of the urea solution now add 19.5 c.c of 
mercuric nitrate solution. Also add the correct number of c.c. of 
soda solution required to neutralize the acid of the nitrate. 

3. Make a pasty mass of chloride — free sodium bicarbonate in 
w r ater, washing off excess of the bicarbonate, if necessary, with a 
little cold water in a beaker and pouring off the water. 

4. By means of a stirring rod transfera drop of the liquid ob- 
tained in 2 to a dark glass plate and there mix it with a drop of 
the semi-fluid obtained in 3. The color should be white. 

5. Continue adding the mercury solution to the urea-carbon- 
ate solution as in 2, drop by drop, and stirring well, and after 
addition of each drop of mercury solution, test as in four. A 
slight yellow color on the plate will finally be obtained, and if the 
mercurv solution is correct just 20 c.c. should be necessary for 
this. 



APPENDIX. 327 



TEST OF THE URINE. 



1. To 50 c.c. of urine add 25 c.c. baryta solution. Shake thor- 
oughly, filter through dry filter into a flask. Filtrate should be 
(a) alkaline, if not (b) precipitate over again with equal parts 
urine and baryta solution. 

2. Take 15 c.c. of the alkaline filtrate obtained in 1 (a) or 20 
c.c. if of (b), and neutralize by adding carefully one drop at a time 
dilute nitric acid. Test with litmus after each drop. 

3. The filtrate thus prepared is titrated with the mercury solu- 
tion. Begin bv adding a c.c. at a time, and after each addition 
bring a drop of the mixture in contact with a drop of the semi- 
fluid sodium bicarbonate on a plate of dark glass. The drops 
should be placed side by side and mixed at the edges. At first 
the mixture remains white, even after stirring, but as the addition 
of mercury is continued a point is reached where the drop from 
the beaker brought in contact with the moist bicarbonate gives a 
light yellow shade. On stirring the drops together this yellow 
should disappear, but this shows that the end of the reaction is 
nearly reached. Add now the mercury solution in drops and test 
after each addition. When the point is reached where a faint 
yellow shade persists after stirring together the drop from the 
beaker and the sodium bicarbonate, it is time to neutralize with 
the normal sodium carbonate solution. Run in the right number 
of cubic centimeters corresponding to the mercury used and now 
make the test for the final reaction again and continue until the 
yellow color appears. 

Regard this test as preliminary and make a new one with 15 c.c. 
of the filtrate neutralized as before. Run in directly within 1 c.c. 
of the amount of mercury required, as shown by the first test, 
neutralize and complete as before. For each cubic centimeter 
used, after deducting for chlorides, calculate 10 mg. of urea. 

4. Deduct for chlorides by determination of the chlorides pres- 
ent in 10 c.c. of urine (see Chlorides), calculate to sodium chloride, 
and for each milligram of it found deduct .0238 c.c. from the vol- 
ume of the mercuric nitrate, or approximately deduct 2 c.c. from 
the volume of the mercury solution. 

5. If more than two per cent of urea is present more than 20 
c.c. of mercuric solution will be needed in the titration. If the 
volume of the latter solution is greater than the sum of the 
volumes of the prepared urine and soda solution used in neu- 
tralization, this sum must be subtracted from the volume of the 
mercury solution and the result multiplied by 0.08. The product 
is added to the number of cubic centimeters of mercuric nitrate 
used, to give the corrected result. If, on the other hand, the 
volume of mercuric nitrate used in titration is less than the sum 
of the volumes of prepared urine and soda solution, the difference 
is multiplied by 0.08 and the product taken from the number of 
c.c. of mercuric solution used, to give the corrected result. In 
these calculations the volume of mercuric nitrate taken up by 
the chlorides must be considered as part of the diluting liquid. 
The same must be remembered in adding sodium carbonate for 
neutralization. 

The correction may be expressed in this formula, according to 
Pflueger: 



328 APPENDIX: Total Nitrogen. 

C=-(V 1 -V 2 )Xo.o8, 
in which 

C = the correction to be added or subtracted. 

V x = the sum of the volumes of the urine, soda solution and 

mercuric nitrate combined with the chlorides. 
V 2 = the volume of mercuric nitrate taken by urea. 
In illustration we may take an actual case: 

15.0 c.c. = the prepared urine (neutralized). 
15.8 c.c. = the sodium carbonate used. 
1.8 c.c. = the mercuric solution used by chlorides. 



\\ = 32.6 c.c. 
V.-) = 26.0 c.c. 



6.6 

—(V 1 —V,)Xo.o8=— 0.528=0. 
Therefore, 26 — 0.5 = 25.5 is the corrected volume of mercuric 
nitrate, indicating, with the latter solution of standard strength, 
2 5-5 S m - of ur ea in a liter.* 

KJELDAHL PROCESS FOR TOTAL NITROGEN. 

Solutions required: (a). Normal sulphuric acid made by 
mixing 30 c.c. of pure concentrated acid, specific gravity 1.835, 
with enough water to make 1050 c.c. The mixture is cooled and 
its strength determined with normal potassium hydroxide (see 
Acidity). It is then dilated with water until 10 c.c. will exactly 
neutralize io c.c. of the normal potassium hydroxide solution. 

(b). Fuming sulphuric acid. 

(c). One-fifth normal potassium hydroxide solution. 

(d ). Solution of sodium hydroxide, specific gravity 1.3. 

(e). Solution of litmus. 

The one-fifth normal potassium hydrate is prepared by intro- 
ducing 100 c.c. of normal potassium hydrate solution into a 500 
c.c. graduated flask and filling with distilled water to the mark. 

The sodium hydrate solution is made by dissolving 320 grams of 
the pure sticks in about 500 c.c. of distilled water, allowing to cool, 
and when cold, introducing into a 1,000 c.c flask and filling with 
water to the mark. 

The litmus solution is made by pulverizing 50 grams of litmus, 
introducing the powder into a flask containing 300 c.c. of distilled 
water, warming an hour or two in a water bath with frequent 
shaking, and decanting through a filter. Divide the filtrate into 
two equal volumes and redden one by introduction of small quan- 
tities of dilute nitric acid, using a glass rod. Then mix the two 
volumes, add 50 c.c. of strong alcohol, and keep in a dark, cool 
place in small bottles filled to the neck, each closed with a cork, 
having a groove cut in one side to allow access of air. 

APPARATUS REQUIRED. 

A 200 c.c. round-bottom Bohemian flask. 

A 750 c.c. Erlenmeyer flask. 

A condenser. 

A 400 c.c. flask as a receiver. 

A safety tube, 50 c.c. burette, etc. 



*IyOiig's Chemical Physiology. 



APPENDIX. 329 



PROCESS OF DETERMINATION. 

Introduce 5 c.c. urine from a burette into a 200 c.c. round-bottom 
flask, and add 10 c.c. filming sulphuric acid. To prevent loss 
while the fluid is heated, introduce (according to Arnold) into the 
mouth of the flask a test tube which fits loosely into its neck, hav- 
ing been enlarged in its upper third by heating in the flame of a 
blast lamp and blowing out. If the enlargement of the test tube 
is near or in the middle third, remove the upper part of the tube 
with a file. Place the flask on wire gauze secured at an angle of 
45 , and heat the fluid with a gas or spirit lamp. Continue the 
application of heat until the fluid becomes light yellow in color. 
This usually takes place in one to one and one-half hours. The 
fluid should be kept in constant ebullition. After cooling, place 
the flask in cold water, as heat is generated by diluting, and add 
water in small quantities, mixing well by shaking gently after 
each addition, and when the dilution has reached about 100 c.c. 
the fluid is introduced into the 750 c.c. Erlenmeyer flask. Rinse 
several times with water, and add the rinsings to the fluid. The 
quantity of fluid in the Erlenmeyer flask should not exceed 200 
c.c. Into the 400 c.c. flask to receive the distillate, introduce 10 
c.c. normal sulphuric acid from a burette. The condensing tube 
of the cooler should be somewhat long, and the end to enter the 
receiver bent, that its orifice may be brought as near the acid as 
possible without coming in contact. As the fluid is dense when 
the solution of sodium hydrate is introduced, it is liable to bump 
during the' distillation, to prevent which small fragments of zinc 
are introduced into the flask. By the action of NaOH on zinc, 
hydrogen is evolved, which prevents the bumping; but it was 
found (Pfeiffer and Lehman u) that the hydrogen and aqueous 
vapor a small quantity of sodium hydrate is carried over, hence a 
safety tube is introduced between the Erlenmeyer flask and con- 
denser. This ; s made by drawing out the end of a combustion 
tube. 20 cm. long and iS m.m. internal diameter, in the flame of 
a blast lamp to 8 or 10 m.m. which passes through a hole in the 
cork of the Erlenmeyer flask. * The upper end of the tube is con- 
nected with the cooler by means of a cork, through which passes a 
bent glass tube. To the fluid to be distilled add 60 c.c. of the solu- 
tion of sodium hydrate (sp. gr. 1.30) and three fragments of zinc 
as nearly spherical as possible, the weight of which not to exceed 
0.5 grm. The sodium hydrate and zinc having been introduced, 
connection with the condenser is made at once to prevent loss of 
ammonia Distill slowly until the ammonia separates from the 
fluid and is carried into the receiver and absorbed by the sulphuric 
acid. This is usually accomplished by distilling thirty minutes. 
To determine with greater accuracy if all the ammonia is distilled, 
place a small piece of red litmus paper at the orifice of the con- 
densing tube, and if ammonia is still passing over, the red litmus 
paper turns blue. 

The quantity of ammonia absorbed by the 10 c.c. normal sul- 
phuric acid is determined by titrating with the one-fifth normal 



*It was found by Dr. Van Nueys that by a safety tube of the dimensions 
here given, the purpose is accomplished as well as with others more complex 
in construction which have been recommended. 



330 APPENDIX: Uric Acid. 

potassium hydrate. For this purpose, the solution of litmus is 
added to the fluid in quantity sufficient to impart a distinct red 
color, when the solution is titrated with the one-fifth normal potas- 
sium hydrate from a 50 c.c. burette, until by the addition of 0.1 
c c, after shaking, the solution turns purple or blue. 

CALCULATION OF RESULTS. 

In 1 c.c. normal ammonia there is 0.017 gram NH S or 0.014 
gram nitrogen. 1 c.c. normal acid will neutralize 1 c.c. normal 
ammonia; therefore, by multiplying the number of c.c. normal 
acid neutralized by 0.017, the product is the quantity of NH 3 in 
grammes, or by multiplying by 0.014, the number of grams nitro- 
gen is determined. 

Example: 31 c.c. of one-fifth normal potassium hydrate was 
required to neutralize the acid instead of 50 c.c, as would be the 
case in the absence of ammonia 31 c.c. one-fifth normal solu- 
tion is equal to 6.2 c.c. of the normal (- 3 5 1 -=6. 2), and as 10 c.c. of the 
normal sulphuric acid was employed, 3.8 c.c. was neutralized by 
the ammonia formed from 5 c.c. urine (10 — 6.2=3.8), and as 3.8 
c.c. normal ammonia would neutralize 3.8 c.c. normal sulphuric 
acid, there is in 3.8 c.c. normal ammonia the quantity of nitrogen 
found in 5 c.c. urine, which is 0.0532 gm. (3.8X0.014=0.0532), and 
in 100 c.c. urine there is 1.064 g m - nitrogen (0.0532X20=1.064). 

THE GUNNING METHOD. 

In this method neither potassium permanganate nor sulphide 
is used, but 10 gm. of powdered potassium sulphate and ordinarily 
20 c.c. of concentrated sulphuric acid. Digestion as in the 
Kjeldahl process, as also dilution, neutralization and distillation. 
In neutralizing it is convenient to add a few drops of phenol- 
phthalein by which one can tell when the acid is completely 
neutralized, remembering that the pink color which indicates 
an alkaline reaction is destroyed by considerable excess of strong 
fixed alkali. Titration as in Kjeldahl method. 

A very satisfactory apparatus is now used by the Connecticut 
Agricultural Experiment Station, which is described in full in 
their annual report for 1889. For use in determining nitrogen in 
the urine the flasks may be made smaller. 

Dr. Long advises use as standard acid one-tenth normal sul- 
phuric acid, which is colored with a single drop of methyl orange; 
the standard acid must still show a pink color after the distillation 
process. 

DETERMINATION OF URIC ACID. 

The principal methods now in vogue are the Salkowski-Ludwig 
and the Haycraft. 

THE SALKOWSKI-LUDWIG. 

Solutions required : 

[a). Ammoniacal silver nitrate solution made by dissolving 25 
gm. of silver nitrate in 100 c.c. of water, adding ammonia water 
until the precipitate first appearing is completely dissolved, mak- 
ing up to 1,000 c.c. with water and keeping in a dark bottle away 
from the light. 

[b). Magnesia mixture made as follows: Dissolve ioogm.of 
magnesium sulphate and 100 gm. of ammonium chloride in 800 c.c. 



APPENDIX. 331 

of water, add ioo c.c. of strong ammonia water, allow mixture to 
stand 24 hours and filter. It must be strongly alkaline and al- 
most or quite clear. 

(c). Solution of sodium sulphide made by dissolving 25 to 30 
gm. of pure crystals (Na 2 S, 9H 2 0) in 1,000 c.c. of distilled wa- 
ter. To make the test measure out 200 c.c. of the urine of 24 
hours and put it in a beaker. Add 20 c.c. of the silver solution to 
an equal volume of the magnesia mixture and then ammonia 
enough to clear up any precipitate which forms. Pour the clear 
mixture into the urine in the beaker and stir well. A precipitate 
of silver urate and phosphates (silver and earthy) forms. 

The beaker is allowed to stand at rest about an hour, after 
which the contents are filtered and the precipitate washed with 
weak ammonia on the filter. To do this the ammonia is sprayed 
into the beaker from a wash bottle and rinsed around thoroughly. 
This is done several times, the liquid being poured on the filter. 
Where available a Gooch crucible serves well for the collection 
of the precipitate, as the filtration is slow on paper without aspir- 
ation. It is not necessary to remove any of the precipitate which 
clings to the beaker, as will be seen. When the washing is com- 
plete transfer the precipitate and filter paper, or asbestos it the 
Gooch crucible is used, back to the beaker and pour over it a 
boiling mixture of 20 c.c. of the sulphide solution {c), and 20 c.c. 
of distilled water. Stir up thoroughly, allow to stand some time 
and then add 50 c.c. of boiling water. Place the beaker on a 
sand bath or gauze and bring the contents to boiling, stirring con- 
tinually. Keep hot some minutes and then allow to stand until 
cold, the precipitate being stirred meanwhile occasionally. 

The treatment with the sulphide solution decomposes the silver 
urate with precipitation of black insoluble silver sulphide, the 
uric acid remaining in solution as soluble urate. The cooled 
liquid is filtered into a porcelain dish, and the precipitate washed 
with warm water, the washings going also into the dish. Enough 
hydrochloric acid is now added to combine with all the bases 
present and liberate the uric acid, which is the case when the 
liquid becomes acid in reaction. It is now slowly evaporated to a 
volume of about 10 c.c, best on a water bath, and then allowed to 
stand an hour for the complete separation of the uric acid. This 
is then collected on a weighed Gooch crucible, the crystals being 
transferred gradually by aid of the filtered liquid. When the 
crystals are on the asbestos they are washed with a little acidu- 
lated water several times. The crucible is dried at ioo C. 
(212 F.), put back in the funnel and treated with a small amount 
of pure carbon disulphide to remove traces of sulphur. Finally 
wash with ether, dry at ico° C, and weigh with a chemical bal- 
ance. 

Results obtained show the amount of uric acid in grams in 
200 c.c. of urine; multiply by 5 to find grams per liter and by 
the number of liters of urine in 24 hours (1,000 c.c. = r liter) to 
find total quantity of uric acid in 24 hours. Reduce this to grams 
by multiplying by 15.43. 

THE HAYCRAFT METHOD FOR URIC ACID. 

Solutions required : 

(a). Ammofiiacal solution of silver nitrate: Dissolve 5 gm. 



332 APPENDIX: Uric Acid. 

of silver nitrate crystals in ioo c.c. of water and then enough 
ammonia water to give solution strong alkaline reaction. Make 
up to 200 c.c. with the ammonia. 

{b). Ammonium sulphocyanate solution: A fiftieth normal 
solution of ammonium sulphocyanate is used which is made by 
diluting 100 c.c. of decinormal ammonium sulphocyanate to 500 
c.c. in a measuring flask. 

[Decinormal ammonium sulphocyanate is made as follows: 
Dissolve about 7.7 gm. of the pure crystals of ammonium sulpho- 
cyanate in water and make up to a liter. Determine its strength 
by titration with decinormal silver nitrate solution made as fol- 
lows: Weigh out accurately 10.766 gm. of pure silver and dis- 
solve in a flask with pure nitric acid. Remove excess of nitric 
acid by evaporation and blow air through to drive out nitrous 
fumes. Cool and dilute to one liter. This solution may also be 
made by dissolving 16.954 gm. of the crystals of silver nitrate 
(fused at low temperature before weighing) in water to make a 
liter, but its strength must be tested, as described under chlo- 
rides. 

Determination of the strength of the decinormal ammonium 
sulphocyanate solution is made as follows: Measure into a flask 
or beaker 25 c.c. of the decinormal silver solution, and add to it 
2 or 3 c.c. of a nearly saturated solution of ferric alum free from 
chlorine. This gives some color and a slight opalescence. Now 
add about 2 c.c. of pure, strong nitric acid which decolorizes and 
clears the mixture. Into the mixture now let the sulphocyanate 
flow a little at a time, shaking after each addition. When the 
red color disappears more slowly on shaking, then add the sul- 
phocyanate drop by drop till at last a single drop is enough to 
give a permanent reddish tinge. Less than 25 c.c. will do this. 
Repeat the test and if the same result is found dilute the sulpho- 
cyanate so that 25 c.c. will exactly do the work. That is, if 24.2 c.c. 
were required, then if you have 900 c.c. of sulphocyanate solution, 
24.2 : 25 = 9oo:x, or x = 929.75. That is, add 29.8 c.c. of water 
to the 900 c r. of sulphocyanate.] 

(c). Ammonium ferric stilphate (ferric alum), saturated solu- 
tion, as indicator. 

One cubic centimeter of a fiftieth normal (f a ) solution of the 
sulphocyanate liberates and indicates .00336 gm. of uric acid. 

If a solution of a sulphocyanate is added to a solution of a sil- 
ver salt containing nitric acid and ferric sulphate, a complete 
reaction takes place between the sulphocyanate and silver before 
the characteristic reaction between the former salt and the ferric 
compound appears. In other words, the sulphocyanate and the 
silver combine first, and then any further amount of sulphocyan- 
ate added unites with the iron, producing a red color (of ferric 
sulphocyanate), indicating the completion of the first reaction. 

The process for determining uric acid in the urine is as follows: 
Measure out 50 c.c. of the urine and warm it gently if it contains 
a sediment of urates. Add 3 to 4 gm. of pure sodium bicarbonate 
and then ammonia enough to give a strong alkaline reaction. 
This may give a precipitate of phosphates which need not be 
heeded. Next add 5 c.c. of the silver solution (a), and mix thor- 
oughly This produces a precipitate of silver urate along with 
the bulky phosphates thrown down by the ammonia. Allow to 
stand half an hour and then filter. A paper filter and funnel may 



APPENDIX. 333 

be used in the usual manner, but much better results are obtained 
by the use of the Gooch crucible and asbestos with the aid of an 
aspirator. Rinse the sides of the beaker thoroughly with weak 
ammonia and pour this on the precipitate in the funnel or cruci- 
ble. Continue the washing of the precipitate with weak ammonia 
water until all traces of silver are washed out, as may be shown 
by allowing a few drops of the filtering washings to fall into some 
dilute hydrochloric acid in a test tube. The washing is complete 
when a cloudiness is no longer obtained in this test. 

Now pour some pure dilute nitric acid into the beaker in which 
the precipitation was made, and which was washed free from silver 
by the ammonia, and shake it around until any traces of the silver 
urate precipitate are dissolved. Put the funnel or Gooch crucible 
over a clean receptacle and pour this acid liquid on the precipitate. 
Silver urate dissolves completely in dilute nitric acid, and enough 
of this is added, a little at a time, to bring about complete solu- 
tion. It now remains to titrate the silver in the solution. To this 
end add 5 c.c. of the ferric alum solution, and if the mixture is 
not clear and colorless, about 2 c.c. of pure strong nitric acid. 
Then from a burette run in the sulphocyanate (b), a little at a time, 
shaking after each addition until a faint red shade of ferric sulpho- 
cyanate becomes permanent. Toward the end of the titration a 
red appears as each drop of liquid from the burette falls into the 
silver solution below, but this color fades out on shaking and does 
not persist until the last particle of silver has been taken up by the 
sulphocyanate. Supposing now that 15 c.c. of the latter solution 
are required to reach this point we have i5X°°336= : .o504 gm. as 
the amount of uric acid in the 50 c.c. of urine taken. A volume as 
large as this would seldom be required, 5 to 10 c.c. corresponding 
to 16.8 to 33.6 mg., is usually sufficient. 

The Hopkins method is one in which, after removal of phos- 
phates, titration by potassium permanganate is used. While easier 
in some respects than the tw r o previous methods, there are certain 
difficulties in it which make it not so preferable to the two methods 
just described as to warrant description in full. 



QUANTITATIVE DETERMINATION OF KREATININ IN 
THE URINE. 

In 240 c. c. of urine the phosphates are first removed by ren- 
dering the urine alkaline with milk of lime and then adding cal- 
cium chloride as long as a precipitate forms. If the volume now 
be less than 300 c. c, water is added to that amount. The mixture 
is filtered after having been allowed to stand for one-quarter to 
one-half hour, and washed with a little water; 250 c. c. of the mix- 
ture are then measured off, slightly acidified with dilute hydro- 
chloric acid so as to prevent any transformation of kreatinin into 
kreatin during the long process of evaporation. This amount is 
evaporated on a water-bath to a syrupy consistence, and then 
thoroughly mixed with 20 to 30 c. c. of absolute alcohol. The 
mixture is poured into a stoppered flask provided with a 100 c. c. 
mark, and after thoroughly rinsing out the evaporating dish with 
absolute alcohol, the washings are also placed in the bottle and 
absolute alcohol added to the 100 c. c. mark. The bottle is thor- 



334 APPENDIX: Kreatinin. 

oughly shaken and set aside in a cool place for twenty-four hours, 
the mixture being agitated from time to time. It is now filtered 
and rendered slightly alkaline with a drop or two of sodium 
carbonate solution, as kreatinin hydrochloride is not precipi- 
tated by chloride of zinc. The reaction, however, should be only 
faintly alkaline, as otherwise zinc oxide will be precipitated. 
The mixture is now slightly acidified with acetic acid. Eighty 
c. c, corresponding to 160 c. c. of urine, are treated with 10 to 15 
drops of an alcoholic solution of zinc chloride, prepared by dissolv- 
ing the salt in 80 per cent, alcohol and diluting with 95 per cent, 
alcohol to a specific gravity of 1.2. The mixture is then well 
stirred and set aside in a cool place for two or three days. The 
crystals, which are usually deposited upon the sides of the vessel 
in the form of wart-like masses, are then collected upon a dried 
and weighed filter, always using portions of the filtrate to bring 
the crystals completely upon the filter. These are washed with a 
small amount of 90 per cent, alcohol until the washings are with- 
out color and give only a slight opalescence when treated with a 
drop of nitrate of silver solution. The crystals are finally dried at 
a temperature of ioo° C. (2i2°F.), and weighed. By multiplying 
the weight thus found by 0.6243 the amount of kreatinin is ob- 
tained. 

Precautions: 1. Albumin and sugar, if present, must first be 
removed. In diabetic urines it is best, after having removed the 
sugar by fermentation, to take one-fifth of the total quantity elim- 
inated in 24 hours, and to evaporate this to about 300 c.c. before 
removing the phosphates. 2. The weighed material should be 
examined microscopically to see whether notable quantities of 
sodium chloride be present. Should such be the case it is neces- 
sary to determine the amount of zinc present and to estimate the 
kreatinin from this. To this end the alcoholic solution containing 
the kreatinin-zinc chloride is evaporated to dryness after the 
addition of a little nitric acid. The residue is incinerated, ex- 
tracted with water, washed, dried, fused and finally weighed. 

As too parts of kreatinin-zinc chloride correspond to 22.4 parts 
by weight of zinc oxide, the corresponding amount of the com- 
pound is found according to the following equation: 22.4 : 100= 
y : x and -#"=4.4642, in which y represents the amount of zinc 
oxide found, and x the corresponding amount of kreatinin-zinc 
chloride. By multiplying the number thus ascertained by 0.6243 
the corresponding amount of kreatinin is found. 

3. Instead of doing this the precipitate in the alcoholic solution 
may be examined microscopically before filtering, and if sodium 
chloride crystals be found, providing that the kreatinin-zinc 
chloride crystals adhere to the sides of the vessel, the sodium 
chloride may be dissolved in a little water and poured off. 

4. If the crystals of kreatinin-zinc chloride adhere very firmly 
to the sides of the vessel, so that their removal would be incom- 
plete, it is perhaps best to dissolve them in a little hot water, to 
evaporate to dryness, and to weigh the kreatinin compound 
directly. 

5. If the urine shows an alkaline reaction it is best to acidify 
with sulphuric acid and to boil for half an hour, before removing 
the phosphates, so as to transform any kreatin that may be pres- 
ent into kreatinin, when the examination should be continued as 
described. (Simon.) 



APPENDIX. 335 



DETECTION OF PARAXANTHIN AND XANTHIN. 

In the examination of the urine Rachford assumes, for reasons 
given in his paper, the following propositions: i. Four liters of 
normal urine is too small a quantity to determine the presence of 
paraxanthin. 2. Three liters of pathological urine are quite 
enough to determine whether paraxanthin occurs in sufficient ex- 
cess in this Urine to make it a probable factor in disease. 

In every case at least two specimens of urine should be exam- 
ined. One of three liters of urine passed during and just after 
the attack, supposed to be due to leucomain poisoning; and the 
other of four liters of urine passed, in an interval between the at- 
tacks, when the patient is at his best. 

Method (from E. Salkowski and Salomon). — The phosphates are 
precipitated with ammonium hydrate; after twenty-four hours the 
urine is filtered or decanted from the precipitate, and a three per 
cent, solution of nitrate of silver is added to it; the silver solution 
should be added as long as precipitation occurs. The urine is 
removed from the precipitate of silver compounds, and this pre- 
cipitate is washed five or six times with distilled water, the water 
being removed each time from the precipitate by decantation. 
This process may require a week. The silver compounds sus- 
pended in water are now decomposed with hydrogen sulphide, 
the current of H 2 S is made to pass through the water, in which 
the silver compounds are suspended, for hours; the liquid is now 
filtered, to separate it from the precipitate, and evaporated down 
to about 50 c.c. if 2,000 c.c. of urine have been used, the remaining 
uric acid is thereby separated; this liquid being filtered, ammonia 
is again added; after twenty-four hours it is again filtered and 
precipitated with silver nitrate, the silver being added as long as 
precipitation occurs; the silver compounds are again separated 
from the liquid by filtration; they are allowed to remain 011 the 
filter paper and kept in a dark place for twenty-four or thirty-six 
hours; the filter paper holding the dry precipitate of silver com- 
pound is put in hot nitric acid of 1.1 specific gravity; the acid 
dissolves the nitrates of xanthin and paraxanthin in the precipi- 
tate, and thus separates them from the nitrate of hypoxanthin, 
which is insoluble in nitric acid; if working with three liters of 
urine, from 6 to 7 c.c. of acid should be sufficient to dissolve the 
xanthin and paraxanthin. After two hours the nitric acid is 
again heated and filtered while hot, so as to insure the solution of 
the xanthin and paraxanthin; the nitric acid solution is now care- 
fully neutralized with ammonium hydrate, and for the third time 
xanthin and paraxanthin are precipitated; the precipitate is 
washed, suspended in water, and again decomposed with hydrogen 
sulphide; this fluid is filtered while hot, and the nitrate is evapo- 
rated to 10 c.c; a little ammonium hydrate is now added, and 
after twenty-four hours the last traces of phosphates and oxalate 
will be precipitated; the liquid is again evaporated on a sand-bath, 
and when the liquid begins to get turbid evaporation is suspended, 
and as the liquid cools the xanthin, if present, will separate out; 
filter and again evaporate to 2 c.c. Again the liquid is allowed 
to cool, so that the xanthin may crystallize out, and the 2 c.c of 
"final fluid" is added to 3 or 4 c.c. of distilled water, and this 
dilute "final fluid" is tested for paraxanthin. If this fluid 
contain paraxanthin — a, the needle-shaped crystals can be 



336 APPENDIX: Chlorides. 

obtained by evaporating a drop on a glass slide; b, the character- 
istic white precipitate should result when a drop of this fluid is 
added to a solution of potassumi hydrate; c, a few drops of this 
fluid when injected hypodermically into a mouse or rat should 
produce the symptoms of paraxanthin poisoning. 

That the crystalline mass that separated out in the final evap- 
orations was xanthin may be proven as follows: Dissolve the 
supposed xanthin cr}'stals and add picric acid, and if xanthin be 
present a precipitate of long white glistening crystals of picrate 
of xanthin will form; or a better test is to mix two or three drops 
of suspected xanthin solution with two or three drops of nitric 
acid, chemically pure, in a porcelain dish, and evaporate over 
flame to dryness, and a yellow precipitate results; to this yellow 
precipitate add ammonium hydrate and heat; if the precipitate 
takes on a purple color xanthin is present. 

The quantity of xanthin present can be determined by carefully 
weighing the crystals that separate out in evaporating down to 
the " final fluid." But for clinical purposes this is scarcely neces- 
sary, as one can judge by the mass of crystals formed whether 
there be a great excess of xanthin or not If there only be a thin 
layer of xanthin crystals at bottom of the final fluid, then the xan- 
thin is not very greatly increased, but if the xanthin crystals sep- 
arate out in much larger quantities, adhering to the sides of the 
glass vessel and forming a mass that cannot be redissolved in 6 
or 8 c.c. of distilled water at room temperature, then it may be 
safely asserted that the xanthin is very greatly increased in quan- 
tity. 

The stomach contents should be diluted with distilled water and 
boiled, and then filtered through filter paper with the aid of a 
vacuum filter; the mass remaining on the filter should be again 
mixed with distilled water, boiled, and again filtered; this fluid is 
then treated in the same w r ay as the urine. 

DETERMINATION OF CHLORIDES. 

The method of Salkowsky-Volhard is as follows: 
Reagents necessary : 

i. A solution of silver nitrate of such strength that every c.c. 
corresponds to o.or gram of sodium chloride. 

2. A solution of potassium sulphocyauide of such strength that 
25 c.c. correspond to to c.c. of the silver nitrate solution. 

3. A solution of a ferric salt saturated at an ordinary tempera- 
ture, such as ammonio-ferric alum. 

4. Nitric acid (specific gravity 1.2). 
Preparations of these solutions: 

1. The silver nitrate to be used for this purpose must be pure, 
the crystallized salt being used. In order to test the purity of the 
salt, about 1 gram is dissolved in distilled water, heated to the 
boiling point, the silver precipitated by dilute muriatic acid and 
filtered off. The filtrate when evaporated in a platinum crucible 
should leave either no residue at all or only a very faint one; 
otherwise it is necessary to recrystallize the salt and test again, 
until the desired degree of purity is obtained. 

To bring the solution to its proper strength 0.15 gm. of sodium 
chloride which has been previously dried carefully by heating in a 
platinum crucible is accurately weighed off, dissolved in a little 



APPENDIX. 337 

distilled water and further diluted to 100 c.c. To this solution a 
few drops of a solution of chromate of potassium are added and 
the mixture titrated with that of silver nitrate containing 29.059 
gm. in 100 c.c. of water. The nitrate of silver will first precipitate 
every trace of sodium chloride present and then combine with the 
potassium chromate forming red silver chromate. The slightest 
orange tinge remaining after stirring indicates the end of the re- 
action. Were the solution of silver nitrate of the proper strength 
exactly, 15 c.c. should have been used, as every c.c. is to represent 
0.01 gm. of sodium chloride As a matter of fact, less will in all 
probability be needed, the solution having been purposely made 
too strong. Its correction then becomes a simple matter, it 
merely being necessary to determine the degree of dilution re- 
quired. Supposing that 29.059 gms. of silver nitrate to have been 
dissolved in 900 c.c. of water, and that 14.5 c.c. instead of 15 c.c. 
had been required to precipitate the 0.15 gm. of sodium chloride, 
it is evident that every 14.5 c.c. of the remaining solution must be 
diluted with 0.5 c.c. of water. It is hence only neccessary to 
divide the number of c.c. of the silver nitrate solution remaining 
by 14.5; the result multiplied by 0.5 represents the amount of 
water which must be added in order to bring the solution to the 
required strength. 

Hence the rule for the correction of a solution which has been 
found too strong: 

N . d 

C= , 

11 
in which C represents the number of c.c. which must be added to 
the solution remaining; N the total number of c.c. remaining after 
titration; and the number of c.c. consumed in one titration; and 
the difference between the number of c.c. theoretically required and 
that actually used in one titration. 

In the example given the equation would then read: 

936.5XO 5 

C— =32.29 

14.5 
32.29 c.c. of distilled water are added to the remaining 936.5 c.c, 
and the strength of the solution tested by a second titration. If 
the solution be found too weak, it is best to make it too strong and 
then to correct, as described. 

2. Preparation of the potassium sulphocyanide solution. 

In order to bring this solution to its proper strength, 10 c.c. of 
the silver nitrate solution are diluted to 100 c.c, 4 c.c. of nitric 
acid (specific gravity 1.2) and 5 c.c. of the ammonia-ferric alum 
solution added, and the mixture titrated with the KSCN solution; 
the end reaction is recognized by the production of a slightly 
reddish color, which persists on stirring. The KSCN solution 
having been purposely made too strong, it will be found that 
less than 25 c.c. will be needed in order to precipitate all the silver 
present. The quantity of water necessary for dilution is ascer- 
tained as above according to the formula: 

N . d 

C= , 

n 

3. The solution of ammonia-ferric alum is a solution saturated 

42 



338 APPENDIX: Chlorides. 

at ordinary temperatures, care being taken to insure the absence 
of chlorides in the salt, which may be effected, if necessary, by re- 
crystallization. 

Method applied to the urine: 10 c.c. of urine are placed in a 
small stoppered flask bearing a ioo c.c. mark, diluted with 50 c.c. 
of distilled water and acidified with 4 c.c. of nitric acid. From a 
Mohr's burette 15 c.c. of a standard solution of silver nitrate are 
added, the mixture is thoroughly agitated and diluted with dis- 
tilled water to the 100 c.c. mark, the silver chloride formed is fil- 
tered off through a dry folded filter into a dry graduate, 80 c.c. of 
the filtrate are placed in a beaker, and after the addition of 5 c.c. 
of the ammonio-ferric alum solution, titrated with the potassium 
sulphocyanide solution until the end reaction — i. e., a slightly red- 
dish tinge — is seen. If necessary, two such titrations should be 
made, the sulphocyanide solution being added 1 c.c. at a time in 
the first, while in the second the total number of c.c. needed to 
bring about the end reaction, less one c.c, are added at once and 
then one-tenth of a c.c. at a time. 

The amount of chlorides present in the urine is calculated as fol- 
lows: Example: — Total quantity of urine 600 c.c; 6.5 c.c. of 
potassium sulphocyanide solution were required to bring about the 
end reaction in 80 c.c. of the filtrate. This would correspond to 
8.125 c.c. for the total 100 c.c. of filtrate representing 10 c.c. of 
urine, as is seen from the equation. 

N: 80— x: 100 
8ox=ioo 11 
x=ioo n 5U 

80 4 
in which x represents the number of c.c. corresponding to iod c.c. 
of the filtrate and N the number of c.c. actually used. 

These S.125 c.c. w T ere used in precipitating the remaining c.c of 
the silver nitrate solution not decomposed by the chlorides. As 
25 c.c. of the potassium sulphocyanide solutiou correspond to 10 
c.c. of the silver nitrate solution, the excess of silver solution in 
c.c. is found by the equation: 

25 : 10— N : x 
then 25 x=ioN 

x= 10N 2N 

25 5 
in which x represents the excess of silver nitrate solution in c.c, 
N that sulphocyanide solution as found in the equation above, x 
in this case being 3.25 c.c. 

The difference between the total amount of silver solution em- 
ployed (z. <?., 15 c.c.) and the excess (z. e., 3.25 c c) indicates, of 
course, the number of c.c. necessary for the precipitation of the 
chlorides in 10 c.c of urine. In the case under consideration 
11.75 cc - were employed. As 1 c.c. of the silver solution repre- 
sents 0.01 gram of NaCl, there must have been present in the 10 
c.c. of urine 0.1175 gram; in 100 c.c, hence, 1.175 grams, and in 
the total amount — i. e., 600 c.c. of urine — 7.05 grams. 

From these considerations the following short rule results: In- 
stead of first multiplying the number of c.c of the potassium 
sulphocyanide solution corresponding to 80 c.c. of the filtrate by 



APPENDIX. 339 

• 
A, as seen from the equation above, and the result by — , in or- 
4 5 

der to find the number of c.c. of the potassium sulphocyanide 
solution representing the excess of silver nitrate in ioo c.c. of the 
filtrate and then deducting the result from 15, it is simpler to 
multiply by ]/ 2 directly and deduct the result from 15, the number 
of grams of sodium chloride contained in 1000 c.c. of urine being 
thus found. This figure is then corrected for the total amount of 
urine. 

n 
Hence the equations, I., x = 15 ; II., 1000 : x : : A : Ch, or 

2 

n 

A(i 5 — ) 
2 

the combined formula Ch= , 

1000 
in which Ch represents the quantity of chlorides contained in the 
total amount of urine, A the amount of urine actually passed, n 
the number of c.c. of the potassium sulphoc3^anide solution used 
in the precipitation of the excess of chlorides in 80 c.c. of the 
filtrate. 

6-5 

(15 ) 

2 

So in the above case Ch=6oo =7-05- 

1000 
The method described may be employed in the presence of 
albumin, albumoses, peptones and sugar; the urine, however, must 
be fresh, so as to insure the absence of nitrous acid. (Simon.) 

DETERMINATION OF THE SULPHATES. 

(a) total sulphates: 100 c.c. of clear, filtered urine are treated 
with 8 c.c. of hydrochloric acid H.12), and heated to the boiling 
point; when 20 c.c. of a saturated solution of barium chloride are 
added. The mixture is kept in the water-bath until the barium 
sulphate has thoroughly settled, which it will do in about half an 
hour. Filter through a Gooch filter with a close-fitting plug of 
asbestos, the whole having been previously dried and weighed. 
Care should be taken never to allow the filter to become dry, and 
small amounts of hot water must be added to the last c.c. remain- 
ing, the final traces being placed upon the filter with the aid of a 
rubber-tipped glass rod. The precipitate is washed with boiling 
water until a specimen of the washings is no longer rendered 
cloudy, even on standing for a few minutes, on the addition of a 
drop of dilute sulphuric acid. Gum-like substances, as well as 
pigments, are removed by washing with hot alcohol (70 per cent.), 
and then filling the filter two or three times with ether. A suction 
apparatus is necessary, and in the absence of a special pump a 
simple glass tube bent upon itself may be employed. 

If a paper filter has been used, it is placed in a weighed plati- 
num or porcelain crucible and ignited. The ash is then heated, 
at first moderately, and almost completely covered with the lid. 
It is then heated, only half covered, from five to seven minutes, 
until the contents of the crucible are white. The crucible when 



340 APPENDIX: Phosphoric Acid. 

cooled is placed in a desiccator and weighed, the* difference be- 
tween the first and the second weight giving the weight of the 
barium sulphate obtained from ioo c.c. of urine. 

A reduction of some of the barium sulphate usually takes place 
during the process of combustion, owing to the presence of or- 
ganic material, so that the weight of the barium sulphate ob- 
tained is actually too low. This error may be corrected in the 
following manner: The barium sulphate is washed into a small 
beaker with a small amount of water, colored red by a few drops 
of an alcoholic solution of phenolphthalein, and titrated with a 
one-tenth normal solution of sulphuric acid until the red color has 
disappeared. Every c.c. of the one-tenth normal solution corre- 
sponds to 0.004 grams of barium sulphate, so that the actual 
amount of barium sulphate contained in 100 c.c of urine is ascer- 
tained by adding the figure thus found to that obtained by weigh- 
ing (see below). 

Quantitative Estimation of the Conjugate Sulphates. 
One hundred c.c. of clear, filtered urine are mixed with 100 c.c. 
of an alkaline solution of barium chloride (see above ), the mixture 
being thoroughly stirred. After a few minutes this is filtered through 
a dry filter into a dry graduate up to the 100 c.c. mark. This por- 
tion, corresponding to 50 c.c. of urine, is now strongly acidified 
with dilute hydrochloric acid and brought to the boiling point. It 
is kept upon the boiling water-bath until the barium sulphate 
formed has settled and the supernatant fluid is clear. The pre- 
cipitate is filtered off, washed, dried and weighed, as described 
above. The barium sulphate thus obtained multiplied by 2 and 
deducted from the amount found according to the first method 
indicates the amount referable to the performed sulphates. The 
molecular weight of barium sulphate 4 being 232.82, that of S0 3 
79.86, of H 2 S0 4 97.82, and of S 32, the figure expressing the 
amount of H.,S0 4 , S0 3 , or S, corresponding to 1 gram of barium 
sulphate, is found according to the following equations: 

232.82:79.86: :i:x, and x— 0.34301. .'. 1 gram of barium sul- 
phate=o. 34301 gram of S0 3 . 

232.82:97.82: :i;x, and x= o. 42015. .\ 1 gram of barium sul- 
phate=o. 42025 gram of H 2 S0 4 . 

232.82:32. :i:x, and x=o.i3744. .'. 1 gram of barium sulphate 
=.q. 13744 gram of S. ■ 

To calculate results it is only necessary to multipty the weight 
of barium sulphate found by 0.34301, 0.42015, or 0.13744 in order 
to ascertain the amount of sulphuric acid contained in 50 c.c. of 
urine in terms of S0 3 , EUS0 4 , or S, respectively. 



PREPARATION OF VOLUMETRIC SOLUTIONS FOR 
DETERMINATION OF PHOSPHORIC ACID. 

(See page 147.) 

1. Weigh out 44.78 gm. of uranium nitrate and dissolve in 
about 900 c.c. of distilled water. 

2. Dissolve 10.085 gm. of pure dry and non-deliquescent disodic 
hydrophosphate to make 1000 c.c of distilled water. 

3. Dissolve 100 gm. of acetate of sodium in distilled water, add 
100 c.c. of 30 per cent, acetic acid and dilute the whole to 1000 c.c. 



APPENDIX. 341 

4. Make a solution of ferrocyanide of potassium 10 gm. to 100 
c.c. of distilled water. Keep in a dark place. 

Transfer 50 c.c. of the phosphate solution to a beaker, add 5 c.c. 
of the acetate solution and heat on the water bath. 

Fill a burette with the uranium solution and by means of a 
glass rod place a number of drops of the ferrocyanide solution on 
a white plate. Run in the uranium solution, stir well with a rod 
and from time to time bring a drop of the liquid in the beaker in 
contact with one of the drops on the plate. As soon as the red- 
dish precipitate appears stop, read off number of c.c. of uranium 
used, and repeat the operation several times until the exact num- 
ber of c.c. necessary to cause the red color to appear be deter- 
mined. Dilute the uranium solution according to the formula: 

N . d 

C= 

n 
in which C will represent the number of c.c. of water to be used 
for dilution, N the total volume of uranium solution left after the 
testing is over, n the number of c.c. of uranium solution necessary 
to cause appearance of the red color on the plate, and d the differ- 
ence between the n and 20 (the latter being the number of c.c. 
theoretically required to precipitate 50 c.c. of the phosphate). 

Suppose, for example, after the tests are over there are 750 c.c. 
of uranium left and that 18 c.c. were required to cause appearance 
of red color on the plate, then 0=750X20 — 18-^18. That is 750X 
2-^-18, or 83.33. Dilute the 750 c.c. of uranium solution with 83.33 
c.c. of distilled water. Test again and it will be found that 20 c.c. 
of the diluted solution will exactly precipitate 50 c.c. of the phos- 
phate solution, as shown by the red color on the plate. The pro- 
cess with the urine has been described on page 147. 

OXALIC ACID. 

Neubauer's Method, modified by Fuerbringer. — The quantity 
of urine passed in twenty-four hours is measured and treated with 
a few c.c. of alcoholic solution of thymol to prevent bacterial 
growth. Treat the urine with ammonium hydrate until, after stir- 
ring, the odor of ammonia is perceptible. Add a solution of cal- 
cium chloride until a precipitate ceases to form, and with acetic 
acid render distinctly acid, avoiding a great excess. The phos- 
phates of calcium and magnesium dissolve in acetic acid, while 
calcium oxalate precipitates with more or less uric acid. Let stand 
twenty-four hours, filter through a small filter paper, collect aud 
transfer the precipitate to the paper, with a glass rod provided 
with a small piece of rubber tubing on one end. Wash with 
water until the wash water is free of chlorides, known by testing 
with a solution of silver nitrate and a few drops of nitric acid. 
When washed, transfer the filter, with precipitate, to a small 
beaker and treat with dilute hydrochloric acid and water, avoiding 
a great excess of the former; warm on a water bath, and stir with 
a glass rod so the acid will come in contact with every part of the 
precipitate. The calcium oxalate will dissolve in the acid, while 
any uric acid present will remain undissolved. Filter, through a 
small filter paper, into a beaker of 250 or 3c*) c.c. capacity, wash 
with water and determine when washed, as before. Evaporate the 
filtrate with wash water to about 200 c.c, transfer from the dish to 



342 APPENDIX: Albumin. 

a beaker, rinse the dish with water and add rinsings to the fluid in 
the beaker when the fluid is rendered alkaline with ammonium 
hydrate, known by turning turmeric paper dark red after the fluid 
is well mixed hx stirring. Having stood well protected from dust 
twenty-four hours, filter through a small filter paper free of ash, 
wash with water until the wash water is free of chlorine, known 
by producing no turbidity when tested with a solution of silver 
nitrate with a few drops of nitric acid. Dry the filter with precipi- 
tate and ash in a platinum crucible, and by the heat of a blast 
flame reduce the oxalate to oxide. Cool in a desiccator and weigh. 
Repeat the process of heating and weighing until the weight be- 
comes constant. Multiply the weight of the oxide by 1.6071 to 
find the weight of oxalic acid. 



QUANTITATIVE DETERMINATION OF ALBUMIN. 

Scherer's Method. — Urine in which albumin is to he estimated, 
if not clear, is filtered. Into a beaker of about 200 c.c. capacity, 
100 c.c. urine is introduced. If the reaction of the urine is not 
strongly acid, add acetic acid until the reaction is decidedly acid, 
but avoid an excess of the acid. Suspend the beaker in a water 
bath and keep the water in the bath at the boiling temperature. 
At the expiration of thirty minutes, if, b)* tiansmitted light, the 
urine is clear between the flakes of coagulated albumen, the pre- 
cipitation is complete. If, however, the urine is cloudy, a small 
quantity of acetic acid is added, the urine stirred, and the heat 
continued, when the separation of albumin in flakes will take 
place. Filter through a filter, having been dried at 110° C. be- 
tween watch glasses and cooled in a desiccator and weighed. The 
albumen, having been transferred to the filter, is washed with water. 
As the filtering and washings are likely to require several hours, a 
filter pump or aspirator bottle may be employed with advantage, 
the filter having the support of a platinum cone. The washing is 
continued until no cloudiness is produced when tested with a solu- 
tion of silver nitrate and some nitric acid. Having been cashed 
with water, wash with about 50 c.c. absolute alcohol, followed by 
about the same quantity of ether. Any fat present is removed by 
the alcohol and ether, and the water is so far removed as to facili- 
tate the drying. The funnel is covered with paper or a glass plate 
and placed upright in an air bath and heated gradually until the 
paper and precipitate are somewhat dry, when the filter, with the 
precipitate, is placed between the watch glasses employed before. 
The heating in the air bath at no C. is continued until the weight 
becomes constant, which is ascertained by heating two hours, cool- 
ing in a desiccator and weighing, repeating the process until the 
weight becomes constant. The difference in weight caused by the 
precipitate is taken as the weight of albumin, except in case the 
urine contains much albumin; when the filter paper and precipi- 
tate are ashed and the ash weighed in a platinum crucible. By 
subtracting the weight of the ash from that of the precipitate, the 
remainder is the weight of albumin, or, instead of ashing, 50 c.c. 
urine may be taken and 50 c.c. water added before acidifying and 
heating. The albumin, when dry, should not exceed 0.3 gm. in 
weight; if less, the quantity of inorganic matter present is very 
small. 



APPENDIX. 343 



QUANTITATIVE DETERMINATION OF SUGAR BY 
FEHLING'S SOLUTION. 

As a rule urines of specific gravity of 1030 should be diluted 
five times, and if the density be still higher ten times. To be 
certain that the proper degree of dilution has been reached, 5 c.c. 
of Fehling's solution are treated with 1 c.c. of the diluted urine, a 
little caustic soda and distilled water being added to make in all 
about 25 c.c. This mixture is thoroughly boiled, and if the fluid 
still remains blue another 1 c.c. of diluted urine added, and so on 
until the last two tests differ by 1 c.c. of urine, the last c.c. added 
causing a separation of cuprous oxide. In this manner the per- 
centage of sugar may be approximately determined. Albumin, if 
present, must first be removed by boiling. 

Ten c.c. of Fehling's solution, diluted with 40 c.c. of water, are 
placed in a porcelain dish and boiled. While boiling, the diluted 
urine is added from a burette, y z c.c. at a time, when, as a rule, 
the precipitated cuprous oxide will rapidly settle, so that gradu- 
ally a white bottom may be seen through the blue fluid, the color 
of which becomes less and less intense upon the further addition 
of urine until, finally, the solution is almost colorless. When this 
point is reached the urine is added only drop by drop, until the 
decolorization is complete. The degree of dilution multiplied by 
5 and the result divided by the number of c c. of diluted urine em- 
ployed will then indicate the percentage amount of sugar. 

Unfortunately, it is difficult as a general rule to determine ex- 
actly the point when all the copper has been reduced, i. e., the 
point at which the blue color has entirely disappeared. When it 
is thought that this has been reached, about 1 c.c. should be filtered 
through thick Swedish filter paper, and the filtrate, which must be 
absolutely clear, acidified with acetic acid and treated with a drop 
or two of a solution of potassium ferrocyanide. If unreduced, 
copper be still present in the solution, a brown color will result, 
indicating that insufficient urine has been added. But if, on the 
other hand, no brown discoloration be noted, it is possible that the 
desired point has already been passed, when the titration should 
be repeated. At times the precipitate will not settle at all, and 
even pass through the filter, so that it is almost impossible to 
determine the end of the reaction. In such cases the following 
procedure, suggested by Cause, will be found serviceable: 

Ten c.c. of Fehling's solution are diluted with 20 c.c. of distilled 
water and treated with 4 c.c. of 1-20 per cent, solution of potas- 
sium ferrocyanide. While boiling, the diluted urine is now added 
drop by drop, until the blue color has entirely disappeared, a pre- 
cipitate not appearing at all with this method. 

In order to obtain reliable results, however, the Fehling's solu- 
tion must be prepared with great care, aud its strength deter- 
mined. This may be done in the following manner: o 2375 gram 
of crystallized cane sugar, pure and dried at ioo° C, is dissolved 
in 40 c.c. of distilled water, to which 22 drops of a 1-10 per cent, 
solution of sulphuric acid have been added. This solution is kept 
upon a boiling water-bath for an hour, when it is allowed to cool 
and diluted to roo c.c. with distilled water. Twenty c.c. of this 
solution will then contain exactly 0.05 gram of glucose, corre- 
sponding to 10 c.c. of Fehling's solution, if this be of the required 



344 APPENDIX: Glycero-Phosphoric Acid. 

strength. If too strong, so that 21 c.c, for example, of the sugar 
solution are required to obtain a complete reduction of the copper, 
the strength of Fehling's solution may be determined according to 
the equation: 20:0.05: :2i:x, and x^o.0525. If too weak, on the 
other hand, so that 19 c.c , for example, are required, its strength 
is similarly determined: 20:0.05: :i9:x, and x=o.o475. If necessary, 
the solution may of course be brought to the exact strength in the 
manner indicated elsewhere, by first making it too strong and then 
ascertaining the required degree of dilution. (Simon.) 

DETERMINATION OF GLYCERO-PHOSPHORIC ACID. 

Sotnischewsky's process is to render the 24 hours' urine alka- 
line with milk of lime and precipitate with calcium chloride. 
Filter, evaporate filtrate, aud extract residue with alcohol. The 
residue not dissolved with alcohol is dissolved in water. To both 
solutions add a solution of ammonia and magnesia and allow the 
mixture to stand 24 hours in order to remove traces of the inor- 
ganic phosphoric acid that may still be present. Filter, render 
the filtrate strongly acid with sulphuric acid and boil for some 
time in order to separate the glycero-phosphoric acid. After 
cooling, solution of ammonia is to be added, when, on standing, 
crystals of ammonium-magnesium phosphate are deposited. 
These are to be collected and weighed, whence the amount of 
phosphoric acid derived from the organic compounds can be 
deduced. 

Another method. — Acidify 250 c.c. of urine strongly with nitric 
acid and boil 30 minutes. (The fumes given off have an over- 
powering odor, so that the flask should be provided with a de- 
livery tube dipping into water.) 

When cold precipitate the phosphoric acid by rendering the 
solution alkaline with ammonium hydrate, and treating with 50 
c.c. of magnesia mixture and ammonium hydrate (50 to 100 c c). 
Mix well and let stand 6 to 12 hours. Filter, aud transfer the 
precipitate to the filter by means of a stirring rod provided with a 
small piece of rubber tubing placed on its end. Wash the pre- 
cipitate with water containing one-third its volume of ammonium 
hydrate. The washing is continued until some of the wash water, 
having been boiled in a test tube to drive off excess of ammonia, 
and rendered acid with nitric acid, ceases to yield a turbiditv with 
a solution of silver nitrate. When the precipitate is washed it is 
immediately transferred to a graduated 250 c.c. flask. This is 
brought about by perforating the filter with a glass rod, and with 
a fine stream of water from a wash bottle every trace of the pre- 
cipitate is removed from the paper. Dissolve the precipitate with 
acetic acid, and with water fill to the mark. (The writer finds 
that it is not easy to dissolve all the precipitate with acetic acid as 
directed; in which case dissolve in nitric acid and reprecipitate 
with magnesia mixture and ammonia as above. ) 

Mix well by shaking. With a pipette introduce 50 c.c. of the 
solution into a 200 c.c. flask, add 5 c.c. of the solution of sodium 
acetate, heat to the boiling point (preferably on a sand-bath), and 
from a burette containing the uranium solution titrate while hot 
and determine as under phosphoric acid. 

Multiply the number of c.c. of uranium solution used by 0005, 
the product of which is the weight of Po0 5 in 50 c.c. of the solu- 



APPENDIX. 345 

tion. Multiply by 20 to get into grams per liter and by the num- 
ber of liters of urine in 24 hours to get grams per 24 hours. Sub- 
tract from the total grams for 24 hours the result of a determina- 
tion of the total phosphoric acid itself, exclusive of glycero-phos- 
phoric acid, and the result is the quantity of glycero-phosphoric 
acid. 

DETERMINATION OF SUGAR BY THE POLARISCOPE. 

Soleil-Ventzke's apparatus is constructed in such a manner that 
if a solution of glucose be employed, the length of the tube being 
10 cm., every entire line of division on the scale will indicate 1 
per cent, of sugar. 

The tube of the saccharimeter should be carefully washed out 
with distilled water, and at least once or twice with the filtered 
urine, when it is placed on end upon a fiat surface, and filled with 
the urine to such a degree that this forms a convex cup at the end. 
The little glass plate is now carefully adjusted, so as to guard 
against the admission of bubbles of air. The metallic cap is then 
placed in position, care being taken to avoid undue pressure. 
The examinations are made in a dark room, an ordinary lamp be- 
ing used, and several readings taken, until the differences do not 
amount to more than one-tenth or two-tenths per cent. The tubes 
should be thoroughly cleansed immediately after the experiment. 

In every case the filtered urine should be free from albumin, 
and, if markedly colored, previously treated with neutral acetate 
of lead in substance and filtered. 

If it be desired to demonstrate only the presence of sugar, the 
compensators are first brought to the zero position. If now, upon 
the interposition of the tube filled with urine, a difference in the 
color of the two halves of the field of vision be noted, the presence 
of an optically active substance in the urine ma}' be assumed, 
and if at the same time the deviation be to the right, the presence 
of glucose is rendered highly probable, while a deviation to the 
left will generally be referable to levulose or oxybutyric acid. 
Indican, peptones, cholesterin, and certain alkaloids, it is true, 
also turn the plane of polarization to the left, but as a rule these 
substances need not be considered, cholesterin occurring but 
rarely, while indican in diabetic urines is usually present in only 
small amounts, and a concurrence of sugar and peptones has not 
as yet been observed Lactose and maltose, which also turn the 
plane of polarization to the right, may be distinguished from each 
other and from glucose by the phenylhydrazin test. Levulose 
turns the plane of polarization to the left. Oxybutyric acid is 
practically always associated with the presence of glucose, and 
may be recognized by allowing the urine to undergo fermentation, 
when the filtered urine will become distinctly gyro-rotatory. 
(Simon.) 

DRUGS WHICH INTERFERE WITH ALBUMIN AND 
SUGAR TESTS. 

A very suggestive resume is given by Mceschel as follows: 
I. Albumin Tests are interfered with by: 

Alkaloids. Benzoates. Oil of Santal. 

Analgen. Benzoinum. Piperazine. 



346 APPENDIX: Albumin and Sugar Tests. 

Antipyrine. Chloroform. Plums. 

Balsam Peru. Copaiba. Styrax. 

Balsam Tolu. Cranberries. 

Benzosol. Hypnone. 

After the administration Of acids, some tests for albumin in the 
urine do not respond. Neutralize such urine with a few drops of 
sodium hydrate and filter. Acidify slightly with acetic acid before 
applying any test. Cloudy urines, also such containing a precipi- 
tate (mucin, medicinal balsams and resins), should be faintly 
acidulated with acetic acid and carefully filtered before applying 
any tests. 

II. Sugar Tests are interfered with by: 

Acetanilide. Kalmia. Salicylates. 

Antifebrin. Morphine. Salol. 

Antipyrine. Mercurialis perennis. Senna. 

Betol. Ol. gaultheriae. Sulphonal. 

Chloral hydrate. Phenacetine. Uva ursi. 

Chloroform. Rheum. Urethan. 

Copaiba. Rumex. Vaccin. myrtillus. 

Epigsea. 

To which may be added : 
Ammonium salts. See b below. Glycerin. 

Benzoates. Glycosuric acid. See e. 

Bromides. Iodides. 

Camphor. Pyrocatechin. 

Carbohydrates. See c. Serum globulin. 

Cubebs. Turpentine. 

Creatinine. See d. Uric acid, urates. See 

d and/. 

a. Temporary glycosuria may be occasioned by poisoning with 
alcohol, amyl nitrite, carbonic oxide, chloral, hydrocyanic acid, 
morphine, sulphuric acid. 

b. Ammonium salts should be removed before testing. Such 
is accomplished by boiling with NaOH until no more ammonia is 
given off. 

c. Under certain conditions some carbohydrates (animal gum) 
may be present in the normal urine, causing reduction. 

d. Creatinine (also uric acid and urates) can be removed by 
precipitating with mercuric chloride, which operation does not 
affect any glucose present. 

e. To remove glycosuric acid in urine of diabetics, acidify the 
urine with H 2 S0 4 and shake with ether, from which it may be 
crystallized. 

f. To test for glucose in urine in which salicylates are the dis- 
turbing compounds, the following course may be adopted: Add 
solution of lead subacetate to the urine, which precipitates almost 
all the salicylic acid, also the chlorides, phosphates and sulphates, 
uric acid, urates, albumin, glycuronic acid, and coloring matter. 
The lead remaining in solution is precipitated with dilute sulphu- 
ric acid, and the excess of acid carefully neutralized with soda or 
potash. Thus prepared, the urine may be tested for glucose with 
the usual reagents. 

g. Nylauder's test is interfered with by the use of arsenic, 
iodides, mercurials, large doses of quinine, salicylates, and 
sulphur. 



APPENDIX. 347 

III. Spectroscopic Influences are exerted by: 

Acetanilide. Chloral hydrate. Salol. 

Antifebrin. Copaiba. Santonin. 

Antipyrine. Epigaea. Sulphonal. 

Benzosol. Frangula. Uva ursi. 

Betol. Kalmia. Vaccin myrt. 

Cascara sagrada. Salicylates. 

IV. Important Suggestions: 

1. The reactions obtained should always be compared with the 
perfectly clear, untested urine contained in the same sized test- 
tube holding an amount of fluid equal to that tested. 

2. Filtration is assisted by slightly acidulating with acetic 
acid. Use a good filtering-paper, preferably doubled, and 
moisten thoroughly with distilled water before using. The filter 
fulfills its purpose only after all the cellulose fibers have swollen 
by absorption. 

3. Filtration through talcum, to remove mucin and bacteria, 
also removes large quantities of albumin and glucose. 

4. Animal charcoal is likewise objectionable. 



DETERMINATION OF THE UROTOXIC COEFFICIENT. 

Acid urine being carefully and exactly neutralized with sodium 
bicarbonate and filtered is injected into the veins of a weighed 
rabbit. The posterior marginal vein on the dorsal part of the 
face is convenient for injection. The weight of the person void- 
ing the urine is taken beforehand and the amount of urine voided 
by him is measured. Day urine should be collected separately 
from night and the toxicity determined separately. The urine is 
injected in small quantities at a time, and the result of each injec- 
tion studied. 

The quantity of normal urine necessary to kill a rabbit varies 
between 30 c.c. and 60 c.c. for each kilogram of weight of the 
animal, or 45 c.c. per kilo on an average. 

Pathological urines are some more poisonous, others less poison- 
ous than normal. 

The amount of cubic centimeters of urine necessary to kill one 
kilogram of animal is found as follows: Multiply the amount of 
urine injected before the death of the animal by i,coo, and divide 
product by weight of the animal in grams. 

Thus, suppose 46 c.c. of urine required to kill a rabbit weighing 
1,600 grams, then, 46 times 1,000 

■ -=28.95 c.c. 

1.600 
of urine for each kilogram of animal. 

To calculate the urotoxic coefficient of any man, divide the 
quantity of his urine passed in a given period, day or night, or 
better, each separately, by the number of c.c. of urine required to 
kill each kilogram of animal. Thus, suppose a man void 700 c c. 
of urine during the working hours, 46 c.c. of which are needed to 
kill a rabbit weighing 1,720 grams. Then, 46 times 1,000 



348 APPENDIX: Analysis of Calculi. 

or 26.74 equals the number of c.c. of urine necessary for each kilo- 
gram of rabbit, and 700 

=26.178 urotoxics. 

26.74 
so-called. If the period during vvhich the urine was collected was 
16 hours, then 26.178 



16 
or 1. 6361, is the urotoxy or unit of toxicity per hour. If the man 
weigh 81 kilograms, then 1.6361 

or 0.2002 

81 
represents the urotoxic coefficient per kilogram of the man's 
weight in an hour. 

In other words, this man voids for each kilogram of his weight 
in one hour what would kill 20.02 grams of living material. 

In determining the toxicity of the 24 hours' urine collect the 
day and night separately, ascertain the toxicity of each in c.c. per 
kilogram of animal, and add together, otherwise if the urines be 
mixed before the toxicity is determined, there will be a loss of 
about one-third A person eliminates during sleep something 
which is partly antidotal to the day urine. 

COMPLETE ANALYSIS OF CALCULI. 

The writer prefers Dr. Long's methods, as follows: 

1. Heat test: Reduce some of the calculus to a powder and 
heat to bright redness on platinum foil. If the powder is com- 
pletely consumed suspect uric acid, ammonium urate, cystin, 
xanthin, organized matter; if the powder is either not consumed 
at all, or only panly so, calcium oxalate, phosphates. 

Uric Acid may be recognized by dissolving a little of the pow- 
der in weak alkali, precipitating by hydrochloric acid, and exam- 
ining the precipitate with the microscope. [The writer finds, 
however, that in the West calculi of uric acid are frequently 
coated with phosphates; hence after dissolving what is possible in 
the alkali, filter and precipitate filtrate with hydrochloric acid, 
letting stand some hours.] 

Ammonium Urate acts as above like uric acid and is further 
recognized by liberation of ammonia (odor) when heated with a 
little pure sodium hydroxide solution. 

Cystin: Dissolve powder in ammonia, filter and allow drops 
of filtrate to evaporate spontaneously on slide. Identify by mi- 
croscope. (See cut of Cystin in the book. ) 

Organized flatter is recognized by odor of burnt feathers when 
heated to redness. 

Calcium Oxalate. — Stones of this substance are very hard and 
break with a crystalline fracture. They are often called "mul- 
berry calculi." When the powder is heated it decomposes, leav- 
ing carbonate, which may be recognized by its effervescence with 
acids. 

Calcium and Magnesium Phosphates. — These leave a re>idue 
in which the metals and phosphoric acid may be detected by 
simple tests of qualitative analysis. The ignited powder is sol- 
uble in hydrochloric acid without effervescence. When ammonia 
is added to this solution in quantity sufficient to give an alkaline 



APPENDIX. 349 

reaction, a precipitate of triple phosphate or calcium phosphate 
appears, which may be recognized by the microscope. 

The above tests are generally sufficient to tell all that is prac- 
tically necessary about the calculus. If more detailed information 
is desired a systematic analysis may be made according to the usual 
methods. 

The writer greatly prefers, however, the following: 
Systematic Analysis. — i. Reduce the calculus to a fine pow- 
der and pour over it some water and finally dilute hydrochloric 
acid in a beaker. Warm gently half an hour, or longer, on the 
water bath. Then allow to cool and filter. 

2. Treatment of the residue. It seldom happens that the cal- 
culus is completely soluble in the weak acid. A residue usually 
remains which may contain uric acid, xauthin, calcium sulphate, 
and remains of organized matter. To prove the xanthin treat the 
residue with warm dilute ammonia and filter. The filtrate con- 
tains the xanthin if it is present. Acidify it with nitric acid and 
add a small amount of silver nitrate solution. This produces a 
flocculent precipitate which dissolves by warming, and crystallizes 
on cooling in bunches of fine needles. 

In the residue free from the xanthin look for calcium sulphate 
by extracting with water and applying the usual tests. This solu- 
tion may contain uric acid which is recognized by evaporation and 
crystallization after adding a little hydrochloric acid. In the final 
residue some uric acid may be also present. Dissolve in alkali, 
reprecipitate with hydrochloric acid, and examine any crystals 
which may form under the microscope. 

3. Treatment of the hydrochloric acid solution. This may con- 
tain calcium oxalate, cystin, the phosphates and possibly some 
xanthin. Look for the last in a small portion of the solution. 
Make this portion alkaline with ammonia, add a few drops of cal- 
cium chloride solution, filter if a precipitate forms and treat the 
filtrate with ammoniacal silver nitrate solution. In presence of 
xanthin a flocculent precipitate forms. 

Dilute the remaining and larger portion of the hydrochloric 
acid solution with twice its volume of water, add enough ammonia 
to give a strong alkaline reaction and then acetic acid to restore a 
weak acid reaction. By this treatment phosphates are held in 
solution, while calcium oxalate, if present, precipitates. Therefore 
allow the mixture to stand half an hour and then filter off any pre- 
cipitate which appears. This precipitate may contain cystin as 
well as calcium oxalate. Cystin may be dissolved by pouring 
ammonia on the filter, and on evaporating the ammoniacal solu- 
tion is obtained in form suitable for microscopic examination. 

The residue free from cystin is dried and heated to redness on 
platinum foil. This treatment converts calcium oxalate into car- 
bonate. Place the foil in a beaker and add some dilute acetic 
acid; an effervescence shows the carbonate. To the clear solution 
add next some ammonium oxalate which gives a white precipitate 
of calcium oxalate, if the latter metal is present. 

Next look for phosphates and bases in the acetic acid solution 
obtained after filtering off cystin and calcium oxalate. More cal- 
cium may be present, in excess of that combined as oxalate, which 
may be recognized by adding a little solution of ammonium oxalate. 
If a precipitate forms treat the whole of the liquid with ammonium 
oxalate, after warming on the water bath, allow to stand an hour 



350 APPENDIX: Mounting Sediments. 

and filter. Concentrate the filtrate to a small volume, transfer to 
a large test-tube and add enough ammonia to produce an alkaline 
reaction. If a precipitate now appear it must consist of magnesium 
phosphate, showing both magnesium and phosphoric acid present 
in the original. If no precipitate appear, magnesium is absent, but 
phosphoric acid may still be present. To find it divide the am- 
moniacal liquid into two portions. To one add a few drops of 
magnesia mixture (white precipitate), and to the other add nitric 
acid in slight excess, and then a few drops of ammonium molyb- 
date reagent (yellow precipitate). Both tests must be successful. 
Ammonium salts are recognized by heating the original powdered 
calculus with pure potassium hydroxide solution; odor of ammonia 
and reaction on red litmus paper (turned blue) in the fumes. 

Sodium and potassium are recognized by treating solution of the 
powdered calculus in hydrochloric acid with pure ammonia and a 
little ammonium carbonate in excess. Let precipitate settle and 
filter. Evaporate to dryness in a platinum dish, and heat residue 
strongly to drive off all ammonium salts. 



PRESERVING AND MOUNTING URINARY SEDIMENTS. 

The method of the late Dr. Charles Heitzmann was to add to the 
thickest sediment (which now can be easily obtained by use of the 
centrifuge) a few drops of a strong chromic acid solution. Let 
stand a week, then gradually add a little chemically pure glycerine 
day after day for three or four days. Let stand for a few days 
more until all water has evaporated, then mount without any addi- 
tion, clean, and surround with asphalt. The exact amounts of the 
chromic acid and glycerine used must be learned by practice. 



TABLES. 

The following tables will save time in figuring. The table at 
the top gives figures more in accordance with the writer's observa- 
tions in each case. The table at the bottom, unless otherwise spe- 
cified, is based on English standards which the writer finds are in 
excess of American. In many cases a deduction of even 25 per 
cent, from the upper table (per cent, of normal average) may be 
made with closer approximation to American standards in health. 
Example: Table 1: — 1360 c.c. is given as average normal for an 
American, but not infrequently we find 950 c.c. voided in 24 hours 
by healthy males, so that care must be taken not to assume figures 
above 75 per cent, in the upper tables as indicating necessarily 
anything abnormal. Figures less than 50 per cent, of normal in 
the upper tables are usually significant of disease if the condition 
is permanent and the weight, diet and exercise are average. 



APPENDIX. 



351 



TABLE I. 

QUANTITY OF URINE) IN 24 HOURS. 



D 



Fluid- 
ounces. 

46. 

43- 

40.83 

38.5 

36.33 

34. 

31.66 

29-5 
27.16 

25- 
22.66 

20.33 
18.16 
1583 
13.66 

n-33 
9- 
6.83 

4-5 
2-33 
1. 16 



Cubic 
centimeters. 

1360 
1290 
1225 

1 155 

I090 

I020 

950 

885 

815 
750 
680 
6lO 
545 
475 
410 
34o 
270 
205 

135 
70 

35 
o 



normal 
av'ge. 

IOO 

95 
90 

85 
80 

75 
70 

65 
60 

55 
50 
45 
40 

35 
30 
25 
20 

15 
10 

5 

2^ 

o 



Fluid- 
ounces. 

37- 
34.83 
33- 
31.16 

29-33 

27.5 

25.66 

23.83 
22. 
20.16 
18.33 
16.5 
14.66 
12.S-3 
11. 
9.16 
7-33 
5-5 
3.66 

1.83 

0.83 
o 



FEMALES. 



Cubic 
centimeters. 



I IOO 

1045 
990 

935 

880 

825 
770 

715 
660 
605 
550 
495 
440 

385 
330 
275 
220 

165 
no 

55 

25 

o 



% 

normal 
av'ge. 

IOO 

95 
90 

85 
80 

75 
70 

65 
60 

55 
50 
45 
40 

35 
30 
25 
20 

15 
10 

5 

2^ 

o 



Ai. 



An. 



I 

r 

Am. I 

\ 

1 

Aiv. 



Etc. 



Etc. 



50 
55 
60 

65 
70 

75 
80 

85 
87 
90 

95 
100 

125 
150 
175 
200 



225 
250 

275 
300 

325 
35o 
375 
400 

425 
45o 
475 
500 
Quantities between 



1500 
1650 
1800 
I950 
2IOO 
2250 
2400 

2550 

2625 

2700 

2850 

3000 

3750 

4500 

5250 

6000 

6750 

7500 

8250 

9000 

9750 

IO500 

1 1 250 

12000 

12750 

13500 

14250 

15000 

1360 and 



IOO 
IIO 
I20 
130 
140 
I50 
160 
170 

175 
180 
190 
200 
250 
300 
350 
400 
450 
500 
550 
600 
650 
700 
750 
800 
850 
900 
950 
IOOO 



40 

44 

48 

52 

56 

60 

64 

6S 

70 

72 

76 

80 

100 

120 

140 

160 

180 

200 

220 

240 

260 

280 

300 

320 

340 

360 

380 

400 



1200 
1320 
1440 
1560 
1680 
1800 
1920 
2040 
2100 
2160 
22S0 
2400 
3000 
3600 
4200 
4S00 
5400 
6000 
6600 
7200 
7800 
S400 
9000 
9600 
10200 
10S00 
1 1400 
12000 



1500 or 1 100 and 1200 are accepted as 



IOO 

IIO 

120 

130 

140 

150 

160 

170 

175 
180 

190 
200 
250 
300 

350 

400 

450 
500 
550 

600 

650 
700 

750 
800 
850 

900 

950 

IOOO 
normal. 



352 



TABLES. 



TABLE II. 

RATIO OF DAY URINE TO NIGHT URINE. 

The author having collected his urine for the 24 hours, day and night, separ- 
ately, during 2S successive days, found the lowest ratio of day to night to be 1.7 
to 1, the highest 7 to 1. On 12 days out of the 2S the ratio was 3 to 1. On 4 days 
the ratio was between 2 and 3 to 1. On only 3 days was it below 2 to 1, and on 
S days it was from 4 up to 7 to 1. I have, therefore, adopted 3 to 1 as a basis on 
which to reckon percentage. 



3 to I 
2.S5 to I 
2.70 to I 
2.55 to I 
2.40 to I 
2.25 to I 
2.10 to I 
1.95 to I 
1.80 to I 
1.65 to I 



DESCENDING SCALE. 

Per cent. 
IOO 

95 
90 

85 
80 



75 
70 

65 

60 

55 



Per cent. 

1-5° to I 50 

1-35 to 1 • • 45 

1 . 20 to 1 40 

1-05 to 1 35 

0.90 to 1 30 

o.75 to 1 25 

o. 60 to 1 20 

0.45 to 1 15 

0.30 to I 10 

0.15 to 1 5 



TABLE III. 



TOTAL SOLIDS IN THE URINE. 



Conversion of grains to grammes and relation to normal averages for a 
weight of 145 pounds. (See also page 32.) 



DESCENDING SCALE. 


ASCENDING SCALE 




Grains. 


Grammes. 


Per cent. 


Grains. 


Grammes. 


Per cent 


899. 


58. 


IOO 


899. 


58. 


IOO 


354-05 


55 1 


95 


943-95 


60.9 


105 


809.IO 


52.2 


9° 


98S.9 


63.8 


no 


764-I5 


49-3 


85 


1033-85 


66.7 


115 


719.2 


46.4 


80 


1078.8 


69.6 


120 


674-25 


43-5 


75 


1122.75 


72.5 


125 


629.30 


40.6 


70 


1168.7 


75-4 


130 


5S4-35 


37-7 


65 


1213.65 


783 


135 


539-4 


34-8 


60 


1258.6 


81.2 


140 


494-45 


31-9 


55 


1303-55 


84.1 


145 


449-5 


29. 


50 


13485 


87. 


150 


404-55 • 


26.1 


45 


1393-45 


89.9 


155 


359-6 


23.2 


40 


1438.4 


92.8 


160 


3I4-65 


20.3 


35 


I483-35 


95-7 


165 


269.7 


17-4 


30 


1528.3 


98.6 


170 


224 75 


14.5 


25 


I573.25 


101.5 


175 


179-8 


11. 6 


20 


1618.2 


104.4 


180 


I34-85 


8.7 


15 


1663.15 


107.3 


185 


89.9 


5-8 


10 


1708. 1 


1 10. 2 


190 


44-95 


2.9 


5 


I753.05 


113.1 


195 


22.475 


i-45 


2K 


1798. 


116. 


200 




. . 




2022.75 


130.5 


225 



APPENDIX. 



353 



Ai. 



An. 



Am. 



Aiv. 



Etc. 



Etc. 





TABLE IV. 








IN GRAINS PER FXUID OUNCE AND GRAMMES PER LITER. 




MALES. 






FEMALES. 




Grains 




%of 


Grains 




%of 


per fluid- 


Grammes 


normal 


per fluid- 


Grammes 


normal 


ounce. 


per liter. 


av'ge. 


ounce. 


per liter. 


av'ge. 


IO.09 


21.50 


IOO 


8.924 


19.OO 


IOO 


9-56 


20.42 


95 


8.478 


18.05 


95 


9.008 


19-35 


90 


8.OO3 


17.IO 


90 


8.589 


18.28 


85 


7.585 


16.15 


85 


8.007 


17.IO 


80 


7.139 


15.20 


80 


. 7.571 


l6.I2 


75 


6.692 


14.25 


75 


f 7.068 


I5-05 


70 


6.246 


I3.30 


70 


6.566 


13-98 


65 


5.800 


12.35 


65 


6.059 


12.90 


60 


5-354 


II.40 


60 


5.556 


H.83 


55 


4.908 


IO.45 


55 


t 5.049 


I0.75 


50 


4.162 


9-50 


50 


4.546 


9.68 


45 


4015 


8-55 


45 


4.036 


8.60 


40 


3.56o 


7.60 


4o 


3.532 


7.52 


35 


3-123 


6.65 


35 


3-332 
I 2.527 


6.45 


30 


2.919 


5.70 


30 


5.38 


25 


2.231 


4-75 


25 


2.OI9 


4 30 


20 


1.784 


3.80 


20 


1. 517 


3.23 


15 


1.338 


2.85 


15 


I.009 


2.15 


10 


0.892 


I.90 


10 


O.507 


I.08 


5 


o.445 


0.95 


5 


I O.256 


0.54 


2^ 


0.225 


O.48 


2^ 


IO.82I 


23.04 


IOO 


10.427 


22.2 


IOO 


II.362 


24.192 


105 


10.948 


23.31 


105 


II.904 


25-344 


no 


11.47 


24.42 


no 


12.445 


26.496 


115 


11. 991 


25-53 


115 


12.986 


27.648 


120 


12.512 


26.64 


120 


.. I3.527 


28.8 


125 


13-034 


27.75 


125 


14.068 . 


29.952 


130 


13-555 


28.86 


130 


14.609 


31.104 


135 


14.076 


29.97 


135 


I5.I50 


32.256 


140 


14.598 


3I.08 


140 


15.691 


33.408 


145 


I5-II9 


32.I9 


145 


1. 16.232 


34.56 


150 


15.640 


33-3 


150 


f 16.773 
17.314 


35-712 


155 


16.162 


34.41 


155 


36.864 


160 


16.683 


35-52 


160 


17.856 


38.016 


165 


17.205 


36.63 


165 


18.397 


39.168 


170 


17.726 


37-74 


170 


I 18.938 


40.32 


175 


18.247 


38.85 


175 


19-479 


41.472 


180 


18.769 


39-96 


180 


20.020 


42.624 


185 


19.290 


41.07 


185 


20.561 


43-776 


190 


19. 811 


42.18 


190 


2I.I02 


44.928 


195 


20.333 


43-29 


195 


21.643 

I 24.349 


46.08 


200 


20.854 


44-4 


200 


51.84 


225 


23.461 


49-95 


225 


27.054 


57-6 


250 


26.068 


55-5 


250 


29.760 


6306 


275 


28.675 


61.05 


275 


32.465 


69.12 


300 


31.281 


66.6 


300 


35.171 


74.88 


325 


33-888 


72.15 


325 


37.876 


80.64 


350 


36.495 


77-7 


35o 


40.582 


86.4 


375 


49.102 


83.25 


375 


43.287 


92.16 


400 


51-709 


88.8 


400 



354 



TABLES. 



TABLE V. 

UREA IN GRAINS AND GRAMMES PER 24 HOURS. 



MALES. 

Grains. Gram's. Approx. % 



D 



Ai. 

An. 

Am. 

Aiv. 

Av. 
Avi. 



4io.75 
390.29 

369-675 
349-215 
328.60 

307-83 

287.525 

267.065 

246.45 

225.99 

204.875 

184.915 

164.30 

143.84 




Grains. 

514.6 

540.33 
566.06 

591-79 
617.52 

643-25 

668.98 

694.71 

720.44 

746.17 

771.9 

797-63 

823-36 

849.09 

874.82 

900.65 

926.28 

952.01 

977-74 
1003.47 
1029.2 

1157.85 
1286.50 

1415-15 
1543.80 



26.50 

25.18 

23-85 

22.53 

21.20 

19.88 

18.55 

17-23 

15-90 

14.58 

13-25 

H-93 

10.60 

9.28 

7-95 

6.63 

5-30 

3.98 

2.65 

1.32 

0.66 



27 
25 
24 
23 
21 
20 
19 
17 
16 

15 
13 
12 
11 

9 
8 

7 
5 
4 
3 
1 



100 
95 
90 
85 
80 

75 
70 
65 
60 

55 
50 
45 
40 
35 
30 
25 
20 

15 
10 

5 
2} 



Grammes. Per cent. 



33-2 

34.86 

36.52 

38.18 

39-84 

41-5 
43.16 
44.82 
46.48 

48.14 

49.80 

51.46 

53-12 

54.78 

56.44 

58.10 

59-76 

61.42 

63.8 

64 74 

66.40 

74-7 
83. 
94-3 
99.6 



100 

105 
no 

115 
120 

125 

130 

135 
140 

145 
J 50 
155 
160 

165 
170 

175 
180 

185 
190 

195 
200 
225 
250 

275 
300 



Grains. 

312.75 

301.94 

285.975 

270.165 

254.20 

238.39 

222.425 

206.615 

190.65 

174.84 

'58.875 

143.065 

I27.IO 

III. 29 

95-325 

79-515 

63-55 

47-74 
31-775 
I5-965 
8.215 



FEMAL 

Gram's. 
20.50 
19.48 
18.45 
17.43 
16.40 

15.38 
M.35 
13.33 
12.30 
II.28 
IO.25 

9-23 
8.20 
7.18 
6.15 
5.13 
4.IO 
3.o8 
2.05 
I.03 
0.53 



ES. 

Approx. % 

21 IOO 

19 
18 

17 
16 

15 
14 
13 
12 
II 
IO 

9 



95 
90 
85 
80 

75 
70 
65 
60 

55 
50 
45 
40 
35 
30 
25 
20 

15 
10 

5 
2) 



Grains. Grammes. Per cent. 



412.3 

432.915 

453-53 

474.145 

494.76 

5I5.375 

535 99 

556.605 

577.22 

597.835 

618.45 

639.065 

659.68 

6S0.295 

700.91 

721.525 
742.14 

762.755 

78337 

803.985 

824.6 

927.675 

1030.75 

1134.825 

1236.9 



26.6 

27-93 
29.26 

30.59 
31.92 

33-25 
34-58 
35-91 
37-24 
38.57 
39-9° 
41-23 
42.56 

43-89 
45.22 

46.55 

47.88 

49-21 

50.54 

51-87 

53-2 

59-85 

66.5 

73-15 

79-8 



100 
105 
no 

115 
120 
125 
130 

135 
140 

145 
150 
155 
160 

165 
170 

175 
180 

185 
190 

195 
200 
225 
250 
275 
300 



Those examining urine in Chicago and vicinity will find the figures in the 
upper half of the page far more common than those in the lower. 







APPENDIX. 




355 








TABLE VI. 












(a.) 












URIC ACID RELATIVE TO WATER. 










DESCENDING 


SCALE. 






' 


MALE PATIENTS. 


FEMALE PATIENTS. 






Grains per 


Grammes 




Grains per 


Grammes 






fluid oz. 


per liter. 


Per cent. 


fluid oz. 


per liter. 


Per cent. 




O.173 


0.37 


100 


O.19I 


O.407 


IOO 




O.164 


0.35 


95 


O.lSl 


O.386 


95 




O.I55 


0.33 


90 


O.172 


O.366 


90 




O.147 


O.3I 


85 


O.162 


0.345 


85 




O.I38 


O.296 


80 


O.I53 


0.325 


80 




O.129 


O.277 


75 


0.143 


O.305 


75 




O.I2I 


O.259 


7o 


O.I33 


O.285 


70 




0. 112 


O.24 


65 


O.124 


O.264 


65 




O.IO3 


0.22 


60 


O.H5 


O.244 


60 




OO95 


0.20 


55 


0.105 


O.224 


55 




O.086 


O.185 


50 


O 095 


O.203 


50 




O.077 


O.I66 


45 


O.086 


O.183 


45 




O.069 


O.148 


40 


O.076 


O.163 


40 




O.060 


O.I29 


35 


O.066 


O.142 


35 




O.052 


O.III 


30 


O.057 


O.I22 


30 




O.042 


O.092 


25 


O.047 


O.I02 


25 




O.O34 


O.074 


20 


O.038 


O.08 


20 




O.O26 


O.055 


15 


O.028 


O.06 


15 




O.OI7 


O.O37 


10 


O.OI9 


O.04 


10 




O.O08 


O.OI8 


5 


O.OO9 


O.02 


5 




O.OO4 


O.OO9 


2^ 


0.004 


O.OI 


2K 




In this tab 


e the average 


of Parkes is chosen, since it 


is lower tha 


n that of 




Yvon-Berlioz 


. But in order to make the average for female patients 


the ratio 




of male to female in the Yvon-Berlioz average is taken. 












(*.J 














ASCENDING 


SCALE. 








O.232 


O.500 


IOO 


0.255 


0.550 


IOO 




O.244 


0.525 


I05 


O.267 


0.577 


I05 




0.255 


0.550 


no 


0.280 


O.605 


no 




O.267 


0.575 


115 


0.293 


O.632 


115 




O.278 


O.600 


120 


O.306 


O.660 


120 




O.290 


O.625 


125 


O.3I9 


O.687 


125 




O.302 


O.650 


130 


0.33I 


0.7I5 


130 




0.3I3 


O.675 


135 


0.344 


O.742 


135 




0.325 


O.700 


140 


0.357 


O.770 


140 




0.336 


O.725 


145 


O.369 


0.797 


145 




O.348 


O.750 


150 


O.382 


O.825 


150 




0-359 


0.775 


155 


0.395 


O.852 


155 




O.371 


O.800 


160 


O.408 


O.880 


160 




0.333 


O.825 


165 


0.420 


O.907 


165 




o-394 


O.850 


170 


0.433 


0-935 


170 




0.406 


O.875 


175 


O.446 


O.962 


175 




0.418 


O 900 


180 


0.459 


O.99O 


180 




0.429 


O.925 


185 


0.472 


1. 017 


185 




0.441 


O.950 


190 


O.484 


I.045 


190 




0.452 


0.975 


195 


0.497 


I.072 


195 




0.464 


I. OOO 


200 


O.5IO 


I. IOO 


200 




0.522 


I.125 


225 


0.573 


1.237 


225 




0.580 


I.250 


250 


O.637 


1-375 


250 




0.638 


1-375 


275 


O.7OI 


1. 512 


275 




0.696 


1.500 


300 


0.765 


1.650 


300 




o.754 


1.625 


325 


O.828 


1.787 


325 




0.812 


i.75o 


350 


O.892 


1.925 


350 




0.870 


1.875 


375 


O.956 


2.062 


375 




0.928 


2.000 


400 


I.020 


2.200 


400 





356 TABLES. 

TABLE VII. 

(a.) 

TOTAL URIC ACID IN 24 HOURS. 

DESCENDING SCALE. 





MALE PATIENTS 






FEMALE PATIENTS. 


Grains. 


Grammes. 


Per cent. 


Grains 


Grammes. 


Per cent. 


8.600 


0.555 


IOO 


8.17 


O.527 


IOO 


8.170 


O.527 


95 


7.76 


O.50I 


95 


7.740 


O.499 


90 


7-35 


O.474 


90 


7.310 


O.472 


85 


6.94 


O.448 


85 


6.880 


O.444 


80 


6-54 


O.422 


80 


6.450 


O.416 


75 


6.13 


O.396 


75 


6.020 


O.388 


70 


5.72 


0.370 


7o 


5.590 


O.361 


65 


5-3i 


0.343 


65 


5.160 


0.333 


60 


4.90 


O.316 


60 


4 730 


0.305 


55 


4-49 


O.290 


55 


4.300 


O 277 


50 


4.08 


O.263 


50 


3.870 


O.250 


45 


3-67 


O.237 


45 


3 -44o 


0.222 


40 


3.27 


0.2II 


40 


3.010 


O.194 


35 


2.86 


O.184 


35 


2.580 


O.166 


30 


2-45 


O.I58 


30 


2.150 


O.139 


25 


2.04 


O.I32 


25 


1. 710 


O.III 


20 


1.63 


O.IO5 


20 


1.290 


0.083 


15 


1.23 


O.079 


15 


0.860 


0.055 


10 


0.82 


O.053 


10 


0.430 


0.028 


5 


0.40 


0.026 


5 


0.021 


0.014 


2^ 


0.02 


O.OOI 


2/2 



9-30 

9.76 

10.23 

10.69 
II. 16 
11.62 
12.09 

12.55 
13.02 

13.48 

1395 
14.41 
14.88 

15-34 
15.81 
16.27 
16.74 
17.20 
17.67 
18.13 
18.60 





(*.) 






ASCENDING 


SCALE. 


0.60 


IOO 


8.80 


0.63 


I05 


9.24 


0.66 


I IO 


9.68 


0.69 


115 


IO.I2 


0.72 


I20 


IO.56 


0.75 


125 


II.OO 


0.78 


I30 


11.44 


0.81 


135 


11.88 


0.84 


I40 


12.32 


0.87 


145 


12.76 


0.90 


I50 


13.20 


0.93 


155 


1364 


0.96 


I60 


14.08 


0.99 


165 


14.52 


1.02 


I70 


14.96 


1.05 


175 


15.40 


1.08 


I8O 


15.84 


I. II 


185 


16.28 


1. 14 


I9O 


16.72 


1. 17 


195 


17.17 


1.20 


200 


17.60 



o.57 


IOO 


o.59 


105 


0.62 


no 


0.65 


115 


0.68 


120 


0.71 


125 


0.74 


130 


o.77 


135 


0.79 


140 


0.S2 


145 


0.85 


150 


0.88 


155 


0.91 


160 


0.94 


165 


o.97 


170 


1. 00 


175 


1.03 


180 


1.05 


185 


1.08 


190 


1. 11 


195 


1. 14 


200 



APPENDIX. 



357 



TABLE VIII. 

PHOSPHORIC ACID IN GRAINS PER FI,UID OUNCE AND GRAMMES 
PER LITER. 



Al. 



Per 
cent. 



95 
90 

85 
80 

75 
70 

65 
60 

55 
50 

45 
40 

35 
30 
25 
20 

15 

10 

5 

2) 

o 



Grains 
per fluid- 
ounce. 

1. 127 
I.070 
1. 014 
O.958 
O.90I 
O.845 
O.789 
0.732 
O.676 
O.66 

O.563 
O.507 
0.450 
0.394 
0.338 
O.281 
O.225 
O.169 
O.II2 
O.O59 
0.028 



FEMALES. 

Grammes 
per liter. 

2.40 
2.28 
2.16 
2.04 
I.92 
I.80 
1.68 
1.56 
1.44 
1.32 
1.20 
1.08 
0.96 
0.84 
0.72 
0.60 
0.48 
0.36 
0.24 
0.12 
0.06 
o 



Per 
cent. 



95 
90 

85 
80 

75 
70 
65 
60 

55 
50 
45 
40 
35 
30 
25 
20 

15 
10 



5 

2^ 

o 



Ai. 



An. 



Am. 



Aiv. 



Etc. 



Etc. 



Note: — In the writer's experience 
When the figures exceed 2.40 or 2. 
figure found by 2.4 or 2.5. 



I05 
no 

115 

120 

125 
130 

135 

140 

145 
150 
155 

160 

165 

170 

175 
180 

185 

190 

195 

200 

225 
250 

275 
300 

325 
350 

375 
400 

the lower half of 
5, which is rare, 



939 
986 
030 
080 
127 

174 
221 
268 

315 
362 

409 

456 

503 

55 

596 

643 

690 

737 
784 

831 
878 

113 
348 
583 
818 

053 

287 
522 

757 

this page 
calculate 



2.0 
2.1 
2.2 
2.3 
2-4 
2-5 
2.6 

2-7 
2.8 

2.9 
3.0 
3.1 

3-2 

3-3 
3-4 
3-5 
3-6 
3-7 
3-8 
3-9 
4.0 

4-5 
5.o 
5-5 
6.0 

6.5 

7.0 

7-5 
8.0 



105 
no 

115 
120 

125 

130 
135 
140 

145 
150 
155 
160 

165 
170 

175 
180 

185 
190 

195 
200 
225 

250 
275 
300 
325 
35o 
375 
400 



is of little value, 
by dividing the 



358 



TABLES. 



TABIvB IX. 



PHOSPHORIC ACID IN GRAINS PER 24 HOURS AND GRAMMES. 



MALES. 

Grains. Grammes. 
49.60 3.20 

47.12 3.04 

44.64 2.88 



Ai. 



An. 



Am, 



Aiv. 



Etc. 



Etc. 



Per cent. 

IOO 

95 
90 

85 
80 

75 
70 

65 
60 

55 
50 
45 
40 

35 
30 
25 
20 

15 
10 

5 
2^ 

TOO 
I05 

110 

115 

120 

125 
130 

135 

140 

145 
150 
155 

160 

165 

170 

175 
180 

185 

190 

195 

200 
225 
250 
275 

300 

325 
350 

375 

400 



FEMALES. 

Grains. Grammes. 
2.6o 
2.47 

2.34 
2.21 

2.08 

1-95 
1.82 
1.69 
1.56 

1.43 
1.30 
1. 17 
1.04 
0.91 
0.78 
0.65 
0.52 
0-39 
0.26 
0.13 
0.07 

2.6 

2-73 

2.86 

2.99 

3.12 

3-25 

3.38 

3-5i 

3-64 

3-77 

3-9 

4.03 

4.16 

4.29 
4.42 

4.55 

4.68 

4.81 

4-94 

5-07 

5-2 

5-85 

6.50 

7.15 

7.80 

8.45 
9.10 

9-75 

10.40 



40.30 

38285 

36.27 

34.255 

32.24 

30.225 

28.21 

26.195 

24.18 

22.165 

20.15 

18.135 
16.12 
14. 105 
12.09 
10.075 
8.06 
6.045 

4.03 
2.015 

1.085 

40.3 

42-3*5 

44-33 

46.345 

48.36 

50.375 
52.39 
54.405 
56.42 

58.435 

60.45 

62.465 

64.48 

66.495 

68.51 

70.525 

72.54 

74-555 

76.57 

78.585 

80.6 

90.675 
100.75 
110.825 
120.9 
130.975 
141.05 
151. 125 
161. 2 



Per cent. 

IOO 

95 
90 

85 

80 

75 
70 
65 
60 

55 
5o 
45 
40 
35 
30 
25 
20 

15 
10 

5 
2^ 

100 
105 
no 

115 
120 

125 

130 
135 

140 

145 
150 
155 

160 

165 

170 

175 

180 

185 

190 

195 

200 

225 
250 
275 
300 
325 
350 

375 
400 



APPENDIX. 



359 



TABLE X. 

RATIO OF UREA TO PHOSPHORIC ACID. 



(Yvon-Berlioz.) 



8. to I 
7.6 to I 
7.2 to I 
6.8 to 1 
6.4 to 1 
6.0 to I 
5.6 to I 
5.2 to I 
4.8 to I 
4.4 to I 
4.0 to I 
3.6 to I 
3.2 to I 
2.8 to I 
2.4 to I 
2.0 to I 
1.6 to 1 
1.2 to 1 
0.8 to I 
0.4 to I 
0.2 to I 



Per cent. 

. IOO 

• 95 
. 90 
■ 85 
. 80 

• 75 

• 70 

• 65 
. 60 

• 55 

• 5o 

• 45 
. 40 

• 35 

• 30 

• 25 
. 20 

. 15 

. 10 

• 5 

. 2% 



(Parkes.) 



10. to 1 

10.5 to I 

1 1. o to I 

11. 5 to 1 

12.0 to 1 

12.5 to I 

13.0 to 1 130 

13-5 to 1 135 

14.0 to 1 140 

14.5 to 1 145 

15.0 to 1 150 



Per cent. 

• • IOO 

• 105 

. . no 

. . 115 

. .120 

• • 125 



TABLE 



15-5 to 1 
16.0 to 1 
16.5 to I 
17.0 to I 
17.5 to I 
18.0 to I 
18.5 to I 
19.0 to I 
19.5 to I 
20.0 to I 
22.5 to I 
25.0 to I 

xr. 



155 

160 

165 

170 

175 
180 

185 

190 

195 

200 
225 

250 



RATIO OF UREA TO URIC ACID. 



40 to 1 is normal according to Yvon-Berlioz and 33 to 1 according to Haigs. 
The writer believes that, when the clinical instruments are used for urea and 
the Heintz process for uric acid, anything below 40 to 1 must be regarded as 
indicating relative excess of uric acid. 50 to 1 may be taken as normal. 





TABLE XII. 






RATIO OF UREA TO SAI.TS. 




Urea. Salts. Per cent. Urea. Salts. Per cent 


O.85 


I 100 1.33 


I ICO 


O.8075 


95 I.396+ 


105 


O.765 


90 I.463 


no 


O.7225 


85 1.529+ 


115 


O.68 


80 I.596 


120 


O.6375 


75 1.662+ 


125 


0.595 


70 1.729 


130 


0.5525 


65 1-795 + 


135 


O.51 


60 1.862 


140 


0.4675 


55 1.928+ 


145 


O.425 


50 1-995 


150 


O.3825 


45 2.061 + 


155 


0.34 


40 2.128 


160 


O.2975 


35 2.194+ 


165 


0.255 


30 2.261 


170 


O.2125 


25 2.327+ 


175 


O.17 


20 2.394 


180 


O.1275 


15 2.46+ 


185 


O.085 


10 2.527 


190 


O.0425 


5 2.593+ 


195 


O.02125 


*Yz 2.66 


200 




• • 2.992 + 


225 




• • 3.325+ 


250 




• • 3-657+ 


275 


... 


• • 3.99 


300 



INDEX. 



PAGE 

Acetone, 232 

Albumoses 195-201 

Allantoin . ._ 104 

Alloxuric bodies 247 

Ammonia 161 

Animal gum 128 

Animal bases in urine . . . 245 
Aromatic compounds . . . 109 
Albumin, chemistry of . . 162 
" significance of . . . 189 
" quantitative determi- 
nation 184 



" tests 

" " acetic acid and 


162 


heat 


176 


11 " acidulated brine 


181 


" " chromic acid . . 


181 


" " clinical test . . . 


164 


11 " ferrocyanic test . 


178 


" " heat and acetic 




acid 


175 


" " heat and nitric 




acid 


174 


11 " Jolles' 


183 


" " metaphosphoric 




acid 


181 


" Millard's . . . 


183 


" " nitric acid . . . 


169 


11 " nitro-magnesian 


173 


11 " perchloride of 




mercury . 


182 


" " phenic-acetic . . 


181 


" " picric acid . . 


181 


" " platinocyanide . 


182 


11 " potassio-mercuric 




iodide .... 


181 


" " Sharp's .... 


183 


" " sodium tungstate 


183 


" " Spiegler's . . . 


182 


" " sulpho-salicvlic 


182 


" " sulphoc}^anide . 


182 


Cl Tanret's .... 


183 


" " trichloracetic. . 


179 


Benzoyl-carbohydrate . . . 


128 


Bile in urine 


236 


Biliarv acids 


238 


Bilirubin 


287 



PAGE 

Blood pigments 236 

Calcium 161 

Carboluria 121 

Cane sugar 231 

Carbohydrates in urine . . 230 

" abnormal 207 

11 normal 128 

Carbon 161 

Carbonic acid 161 

Chlorides 151 

" chemistry of . . .151-152 

" physiology 152 

" pathology . . . 153 
" microscopical appear- 
ance 156 

Cholesterin 286 

Chromogens 124 

Coloring matters . . . 236 

" '• abnormal . 236 

" " normal . . 122 

Colors of urine 240 

" due to drugs .... 241 

Color of urine 43 

Collection of urine .... 19 
Conjugate sulphates . . 111-115 

Consistency of urine ... 38 

Cumarin 1 10 

Cystiu 267 

Day urine 18 

Dextrin 230 

Diacetic acid 233 

Diastase 130 

Diazo reaction 242 

Ehrlich's reaction .... 245 
Ethereal sulphates . . .111-112 

Enzymes 130 

Fibrin 203 

Filtration 48 

Fluorine 161 

P'atty acids . 126 

Gases in urine 41 

Glucosazon 128 

Glycero-phosphoric acid . 127 

Glycuronic acid 231 

Glycuronic acid compounds no 

Globulin 193 

Hsematoporphyrin . . 123, 236 



362 



INDEX. 



PAGE 

Hsematoidin 287 

Haemoglobin 201 

Hippuric acid 109 

Histon 205 

Hydroparacumaric acid . . no 

Hydroquinone 121 

Indican 116-121 

Inosite 128 

Iron 161 

Kreatin 104 

Kreatinin 104 

L,actic acid 126 

Lactose 129 

Laiose 231 

Levulose 230 

Leucin 269 

Leucomaius 245 

Maltose 230 

Melanin 240, 287 

Mucus 130 

Night urine 18 

Nitric acid 161 

Nitrogen . 161 

Nucleo-albumin .... 203-205 

Odor of urine 40-44 

Oxalic acid 126 

Oxybutyric acid 235 

Oxygen 161 

Oxyphenylacetic acid ... no 

I*aracresol 121 

Paraxanthin 106 

Pathologic urobilin .... 238 

Pentose 231 

Pepsin 130 

Peroxide of hydrogen . . . 161 

Phenol 121 

Phosphates 131-150 

*' detection of . . . 137-139 

" determination of . 147-150 

pathology of . . 140-145 

" physiology of . .135-137 

Physical characteristics of 

urine 28 

Ptomains 130, 245 

Pyrocatechin . ...... 121 

Quantity of urine in twenty- 
four hours . . .20, 21, 23, 24 
Reaction of urine . . 37, 45, 52 

Rennet 130 

Sediments 253 

" ammonio -magnesium 

phosphate . . . 273 

" bacteria 315 

" blood 289, 293 

" calcium carbonate 278, 282 



PAGE 

Sediments, calcium sulphate 

268, 271 
" connective tissue . . 314 
" crystalline calcium 

phosphate .... 280 
" crystalline magnesium 

phosphate .... 283 

" cystin 267 

" earthy phosphates . . 277 
" epithelium .... 299, 302 
' ' extraneous obj ects 308-309 

" fat 285 

" hippuric acid .... 268 

" indigo 284 

" kreatinin 269 

" leucin and tyrosin . . 270 
" oxalate of lime . . . 264 

" parasites 317 

" pus 294, 298 

" soaps of lime and 

magnesia 283 

" spermatozoa .... 314 
" triple phosphate . . . 273 
" tube casts .... 303, 313 

" urates 260 

" uric acid 257 

" xanthin 272 

Sulphates 157 

" preformed 157 

" physiology of . . . . 158 
" pathology of ... . 159 

" conjugate 159 

Skatoxyl 120 

Specific gravity 45 

Succinic acid 126 

Sugar, quantity of ... . 220 
" significance of . . 228-230 

Sugar 207 

" Allen's test 217 

" bismuth test . . .214-227 
" Briicke's test .... 227 
" Carwardine's test . . 222 
" chemistry of ... . 207 
" clinical test . . . 207-211 

" cupric test 221 

11 Fehling'stest . . . 212 
" fermentation test . . 215 
" Haines' test . . . . 207 
" indigo-carmine test . 219 
" Nylander's test . . • 214 
" picric acid test . . . 222 
" phenylhydrazin test . 217 
" polarimetric test . . 222 
" Purdy's quantitative 

test 221 



INDEX. 



363 



PAGE 

Sugar quantitative ferment- 
ation method . 220, 227 
" Trommer's test . 217, 226 
Sugar, Whitney's test . . . 223 
Toxicity of urine . 249-252 

Typhoid reaction ..... 242 
Total solids in urine . . . 30, 51 

Tyrosin 269 

Urea 54-70 

" physiology of . . . 71-74 
" pathology 74-83 



PAGE 

Uric acid, chemistry of 

85-92, 100-103 

Uric acid, physiology of . 93-97 

" " pathology of . 98-100 

Urinometer 29 

Urochrome 122 

Urohsematin 124 

Uroerythriu ....... 123 

Uroroseinogen 125 

Urospectrin 123 

Xanthin, sediment of . . 272 



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